2017 PSOW - Suzanne Martens Presentation

Wisconsin Department of Health Services
Division of
Suzanne Martens, MD, FACEP, FAEMS, MPH, EMT
WI EMS/Trauma Medical Director
Paramedic Systems of WI 2017

Overview
2
 EMS Activities/Topics
 EMS Office Suggestions
 Assisted Medications Protocol
 DEA Points
 Future Goals
 Narcotic Diversion Example

Reminder of Just Culture
4
Assume Good Intent
Just Culture – Not Blame. Also not carefree.
A just culture has zero tolerance for reckless behavior.

Since Last Year….
5
 New slide background!
 Working towards easier legal name change
 Elite QA reports to follow advanced skills and interfacility
transfers
 PAC/EMS Board updates

PAC Projects/Updates
6
 Expanded pressor recommendations
 Dopamine, Epi, Norepi, Vasopressin, Phenylephrine
 Push-dose pressor option
 Defining minimum meds/skills for Paramedic
 Will continue for other scope levels
 Example of using Elite to define med use/need
 Support of the CARES registry
 Elite QA problems

Suggestions from the EMS Section

Suggestions from the Section
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 Stay within Scope of Practice
 DEA certification current?
 With agency address and Medical Director
 Review your Op Plan; have another person look at it
 Special Events need to be added to the Op Plan
 If recurring, list as such and save time/work
 What is your QA/CQI plan?
 Check Medications use
 If not using them, just an added cost to stock and maintain them
 Medical Directors need E-licensing accounts
 RN/PA/Physician as staff need E-licensing accounts

Additional Suggestions from Me

Additional Suggestions
10
 Recheck the extent of your agency’s scope of practice
 An agency CANNOT perform an interfacility transport unless
the 911 response is covered
 The Bedside Report is NOT a substitute for actual training
and Op Plan updates

Topics to Consider in Protocols
11
 EMR-EMT ambulance staffing
 Selective Spinal Immobilization/Spinal Motion Restriction
 D10 instead of D50
 IM Epi
 Highly potent Opioid considerations, planning, media-driven
hysteria
 Not “Narcan resistant” … any more than a large fire is
“water resistant”

Assisted Prescribed Emergency Medications
with Medical Control Contact (Adult/Peds)
13
 Background
 More people are being treated as an out-patient or with home
care
 EMS will encounter more people with complex medications
 The Physicians Advisory Committee (PAC) acknowledged
that this scenario will become more frequent; the exact list of
medications cannot be maintained as current
 Protocol was not officially posted

14
 Reference:
 Treating Patients with Immediately Life-Threating Conditions Requiring
Previously Prescribed Medications Not Routinely Carried by EMS,
Prehospital Emergency Care, 21:1, 86-87
 The NAEMSP® believes:
 State and/or local entities with jurisdictional authority to regulate EMS
practice in a specific area of service should enact regulations that enable
EMS providers to assist with administering emergency prescribed
medications carried by a patient via routes of delivery that are:
 1) within the provider’s scope of practice; and
 2) approved/allowed by the jurisdictional authority that governs the area in
which the EMS provider is giving care.

15
 To provide guidelines and authorization for the use of
emergency medications not commonly used. For emergency
use only. This protocol is not to be used for interfacility
transfers.
 The patient must exhibit the signs and symptoms for which
the medication is prescribed.
 Medical Control must be contacted and approve the use
of the medication.

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 EMR / EMT / AEMT / INTERMEDIATE / PARAMEDIC
 Routine Medical Care
 Other treatments will be in accordance with protocols particular
to presentation.
 May allow patient/caregiver/school healthcare giver to
administer medication(s) by mouth, rectally, intranasally or
injection.
 The route is the most pertinent consideration. Assist the pt.

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 Identify the medication(s) that is requested by patient, patient’s
caregivers or school official(s)
 Patient, Caregiver or Schools must provide the medication(s) to be administered
 Patient, Caregiver or Schools must provide a written copy of the physician order and care
plan for attachment to the patient care report
 This documentation by the patient’s primary physician should list the following:
 Name of the patient
 Name of the physician
 Document must be signed by the physician
 Contact phone number of the physician
 Name of medication(s)
 Signs and symptoms for which the medication(s) is/are prescribed
 Dosage of the medication(s)
 Number of repeat doses of the medication(s)
 Route(s) of administration(s)
 Potential side effects of the medication(s)

18
 Contact Medical Control to see if the medication(s) may be
given and to discuss any issues regarding administration.
 As long as the provider and the service have the “Medication
Administration Route” for the patient’s medication within their
scope of practice, they may administer the drug by that route
with Online Medical Control Approval.

19
 Copies of the care plan and physician order must be attached
to the patient care report
 If the medication(s) is/are not administered, documentation
must include reasons for withholding
 Whenever medication is administered under these
circumstances, transport is mandatory [emphasis added]

20
 Examples of conditions needing rare medication administration:
 Adrenal Crisis
 Indications:
 Patient has a known history of adrenal insufficiency or Addison’s disease.
 Presents with signs and symptoms of adrenal crisis including any or some of
the following: Pallor, headache, weakness, dizziness, nausea and vomiting,
hypotension, hypoglycemia, heart failure, decreased mental status, or
abdominal pain.
 Assist with administration of patient’s own hydrocortisone (Solu-Cortef) in
its prescribed dosage.
 Typical dosages are 100 mg IV or 1-2 mg/kg pediatric dosage maximum
of 100 mg or sometimes:
 0-3 years old: 25 mg IV
 3-12 years: 50 mg IV
 12 years and older: 100 mg IV

21
 Examples of conditions needing rare medication
administration:
 Hemophilia- Need Blood Factor concentrates when traumatic
injured or spontaneously bleeding

22
 Emphasis:
 Assist people with emergency home-use medications
 The medications are prescribed and dosed for them
 Need to deliver via route within scope/skill

23
 Good description of urgency and impact:
“I will be in the living room, right inside the patio doors. I may be
laying on the carpet or tile. I will have a ziplock bag in my arms.
This bag will have the Solu-Cortef vial, current medical
information and emergency contacts.”
“I will need an IV started, and aggressive (push) volume
replacement (dextrose 5% in normal saline solution is the best).”
 This is where we described the procedure for an IO and she
agreed to it.

24
 Good description of urgency and impact:
 The Solu-Cortef needs to be injected into the IV, not
intramuscular.
“At this point of my adrenal crisis, intramuscular seems to have
little to no effect, and I have a significantly more effective
response to IV administration.”
“The quicker I get the Solu-Cortef and fluids, the quicker I will
stabilize. Delays lead to weeks or months long recovery time for
me. More delays could cascade into my death.”

25
“I will be confused, agitated, extremely fatigued, weak, crying,
dehydrated and nauseous. I will have vomited already.”
“My blood pressure may be high, as I will have already taken
hydrocortisone orally in order to try and ward off the adrenal
crisis. I may have tried to give myself a intramuscular Solu-
Cortef injection, to try and buy some time.”
Whether I did or not does not change the steps listed above.
“I will understand very little of what is said to me, and I will
remember next to nothing of the previous hours and the hours
to come.”

26
 The best and only way to resolve all of this is the Solu-Cortef
and fluids.
“Anti-nausea medication or calming medication will have no
effect, and has proven to make things worse for me.”

27
 I have attached a handout about adrenal insufficiency from a
Texas EMS continuing education program.
 Adrenal Insufficiency: Considerations for the Prehospital
Provider; Texas EMS Magazine May/June 2013

Tips from the DEA Office
30
 The latest legislation is still pending

31
 The DEA certificate is the responsibility of the Physican
Medical Director
 Check the counts
 Check the orders
 Extra orders have been processed by Service Directors
 Do your own application and keep your own information
 False DEA certificates have been obtained by Service Directors
 No one wants to be suspicious or feel betrayed, especially in
community or volunteer agencies

32
 Take care in processing controlled substances
 Never have only one person handling the transactions
 Ordering
 Stocking
 Accountability
 Waste
‐ MUST be witnessed
‐ Simply squirting on the bay floor or dirt outside NOT adequate
‐ MUST render unusable and unretrievable
‐ Destroyed versus Reverse Distribution

My Additional Comment: Biennial Inventory
33
 Narcotic Treatment Programs Best Practice Guideline PART 6
 RECORDKEEPING
 DEA requires that NTPs keep a record of all medication received, dispensed,
administered, and destroyed. In addition, DEA requires that NTPs retain all
records for two years from the date of execution….
 DEA requires that NTPs conduct an initial inventory of all stocks of controlled
substance medications on hand on the date that the NTP begins operations. It is
also required that, at least once every two years, each NTP conduct and
document a physical inventory (called a "biennial inventory") of the medication
on hand. These inventories must include all forms of medication on hand (i.e.,
liquid, tablet, diskette, or powder) as well as the quantity and strength of each
medication.
 https://www.deadiversion.usdoj.gov/pubs/manuals/narcotic/part6/
 My Trick or Treat is the last week of October. Choose your own.

Paramedic Pleads Guilty
to Tampering with Morphine Supply
34
My comments
 Considerations beyond pain management for harmful
outcomes to patients:
 Infectious Disease
 Insurance fraud
 DEA investigation
 Loss of community trust
 Loss of contracts
 Loss of internal trust within the agency

Future Projects
36
 EMS Example Protocol updates based on the National Model
EMS Clinical Guidelines, Version 2
 373-page document courtesy of NASEMSO
 Evidence-Based Guidelines [Connecticut]
 Minimum requirements for each scope
 Update in controlled substances document to reflect new
requirements based on legislation
 Disposal vs Reverse Distribution guidelines

Future Projects
37
 Medical Director exit interviews
 Elite reports
 Trends in medication use
 Trends in chief complaint/call type
 Safety check for IFTs, Emergent Transports
 Advanced airway management safety check
 Considerations for using AHLS guidelines/medications at the
Paramedic (or as appropropriate) level
 MCI/regional event considerations

Narcotic Diversion Case Example
Paramedic Pleads Guilty to Tampering with Morphine Supply

39
 Reported by EMS World on Sept 15, 2017 [excerpts]

40
 Reported by EMS World on Sept 15, 2017 [excerpts]
 A regional ambulance district is defending its security
procedures after revelations that a former paramedic took
painkilling drugs and gave vials of water to patients who
needed pain relief.
 The ambulance district issued a statement that it was "proud
of the fact" that its inventory control and drug security
procedures helped catch the problem.

41
 The paramedic confessed that he started tampering with
drugs in March 2014, following a tonsillectomy.
 The ambulance chief told investigators he first learned of a
problem with the morphine supply on Jan. 30, 2015.
 Special agents with the Food and Drug Administration
[presumed typo: not FDA, but DEA] were notified of a
possible drug tampering situation about five weeks later, on
March 4, 2015.

42
 There were other signs that something was amiss.
 Federal court documents show that Comstock was nearly two
hours late for a training session on Feb. 21, 2015.
 "The captain stated Comstock was still in his bunk sleeping"
 "For 10 minutes, they knocked on his door with no answer.
Eventually, Comstock responded but appeared very groggy
and could not recall how long he was asleep.“

43
 The chief ordered a urine analysis, but it did not appear to
test for fentanyl or morphine, according to the plea
agreement.
 Those were the two drugs at the center of the investigation.

44
 Bethany NTA employees told federal investigators that they
had heard Comstock was suspected of drug tampering in
Gallatin, Missouri, according to the plea agreement.

45
 Ultimately, Comstock pleaded guilty to three counts of
tampering with fentanyl and morphine with what federal
charges described as "reckless disregard for the risk that
another person would be placed in danger of death or bodily
injury."
 There was no indication in court documents that Comstock's
actions caused long-term harm to patients.
 Comstock admitted that on two occasions he personally
treated hip fracture patients who were supposed to receive
pain relief but instead received vials of water.

46
My comments
 Considerations beyond pain management for harmful
outcomes to patients:
 Infectious Disease
 Insurance fraud
 DEA investigation
 Loss of community trust
 Loss of contracts
 Loss of internal trust within the agency

47
 He told federal authorities he tampered with drugs on three
different dates in 2015 but that he had "tampered with drugs
on all the ambulances" prior to March 23 of that year.

48
 Comstock started working for the Gallatin ambulance
company in 2013 and left voluntarily June 2014.
 He stopped by the Gallatin office on two occasions in
February of 2015. After both instances, employees noticed
signs of tampering to vials of fentanyl.
 Shortly after that, federal agents installed surveillance
equipment at the Bethany ambulance building and placed a
camera on an ambulance that was taken out of service.

49
 Surveillance equipment
 Building
 Ambulance that was out of service, but stocked
 The very next day, Comstock was viewed entering the
ambulance to access the narcotics cabinet.

50
 The director for the Community Ambulance District in Daviess
County, read a prepared statement to the News-Press that
was similar to NTA's statement.
 Asked if the problem could have been caught sooner, he said
this: "I just know we take a lot of pride in the fact that we did
catch the problem. We took care of the issue when we came
across it."

51
 Because of its cooperation with authorities, NTA ambulance
officials don't believe the district's state and federal licensing
will be in jeopardy.

52
 Officials in Bethany, in a statement, said the case illustrates
scale of the opioid epidemic that kills 68,000 people a year in
the United States.
 "Unfortunately, the EMS community is not immune to this
tragic epidemic," the ambulance district said.

53
 Summary/Discussion
 How alert are you to tampering with controlled substances?
 You must inform the DEA within 24 hours of suspected
discrepancy or diversion
 Numbers/stock versus clinical/field diversion
 Discussion on waste versus tested destruction of leftover
medications
"Unfortunately, the EMS community is not immune to
this tragic epidemic," the ambulance district said.

2017 PSOW - Suzanne Martens Presentation

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