Episode 192 - What Can EMS Learn From An Emergency Pharmacist? - Part 1

[Music] Hello everybody welcome again to another dissent at the MCHD paramedic podcast. This is Dr. Casey Patrick and we have a super special guest joining us today on the podcast to talk about an issue that I believe is a paramount importance to us every single day on the truck. It does not get enough attention. It's really going to be one of our major focuses clinically here at MCHD during 2026 and that is med-air reduction and who better to talk about us, talk about with us regarding this subject is one of my colleagues in the emergency department and really an expert in this area and that is an emergency department pharmacist. This is Kevin Mercer and he's been kind enough to join us today on the podcast to talk about how we give medicine both in the emergency department, how we administer medication in the field and some of the caveats that exist there, there's a lot of overlap, there's also similarities and differences. But before we get into the discussion Kevin tell the listeners about yourself, about your roles, some of the spots where you work and teach and how you became interested in the interaction between pre-hospital EMS and emergency medicine and pharmacy and how all those folks have to work together to try to improve clinical care and improve safety. Yeah well thank you for having the Dr. Patrick. It's great to be here to talk to you and to your paramedic audience. I love working alongside the paramedics that I see in the emergency department, it's always been a good interaction between the two of us, I feel like there's more similarities than differences. But before we get into it, I guess my name is Kevin Mercer, I'm a pharmacist and emergency medicine pharmacist specifically. I'm an assistant professor of practice at the University of Texas at Austin College of Pharmacy and then I'm an emergency medicine pharmacist for the HCA Houston Healthcare system specifically now with the Kingwood Medical Center. I originally am from Kentucky and I got my doctor of pharmacy and master of public health degrees from there before I pursued some residency training so something that your listeners may not know as much about is that pharmacists can do residency training so there's like a first year that's pretty general and then a second year where you can specialize and actually pursue like the specialized emergency medicine training. We go through the match and the whole thing so maybe we can talk about that if that's something that interests your learners. But right now I pretty much just practice with HCA Houston Healthcare Kingwood in the emergency department seeing patients alongside of nurses, physicians and paramedics. And I also coordinate an emergency medicine pharmacotherapy course at UT in Austin that's your remote and we talk about all things from stroke, sepsis, stemmy, cardiac arrest, trauma, you name it. But specifically looking at the data and the pharmacology and the pharmacotherapy that goes into that. You had a bunch of questions for me so I guess for the first one that's a little bit more about me but what really made me interested in the interaction between EMS and emergency medicine pharmacy is that EMS is a huge portion of our highest stakes medication decisions and I think all of those decisions are really important and we start in the field. The handoff that we get between EMS and the initial interaction when they're rolling a patient into the critical care base or maybe just at the front by the secretary or wherever it might be. I think it's really key and it's often overlooked and I think that that's such a critical piece of the patient's journey in the emergency department. Most are often the first clinicians that are making these real pharmacotherapy decisions for a patient. Often there are no always without labs, without a met list sometimes and usually without a second set of eyes and a lot of what I do in the emergency department is provide those second checks that layer of reassurance that I really enjoy. That's what really got me interested in the interaction between EMS and pharmacy. What was your last question? Well, that was pretty much it. I know your roles in your training and I believe that definitely will be interesting to our listeners to know how in-depth it takes you to get to where you are and so I hope that reflects a certain level of expertise as we walk through to this through the discussion. I also believe it's good for the paramedic listeners, the EMTs, the AMTs, the folks that are out there on the front lines to know how valuable that first 15, 20, 30 minutes of care is to us in the emergency department, both the emergency physicians and the pharmacists specifically from the medication administration standpoint to understand what's been given so far because oftentimes that is just a key facet to where are we going to go from here. If you ignore that initial information and maybe even a half-med list, what pill bottles were strummed about, were there any bracelets, all those sort of core tenets of pre-hospital care, I know sometimes it can feel like that from the medics perspective that we in the emergency department can blow that off and when and if we do, that's at our own peril because oftentimes we're missing really, really important pieces there that can make the second decision and the third decision and so on and so forth that we make both from a pharmacist standpoint or an emergency physician standpoint, much more efficient, accurate, impactful for the patient's outcome if we can put the initial pieces of the puzzle together and you hit on a huge point there and that is the medics are doing this in the field without labs and without imaging and oftentimes with an incomplete med list so it is definitely a tightrope to say the least. I do not want to get too far off topic here but I have to mention that there are two Kentucky graduates on this discussion today, I as well am a Kentucky and spent some time in Lexington as well so that may be a warning to the listeners I don't know but I have to get a go big blue out there and just acknowledge that there are two of us here but back to the regularly scheduled program. I'm going to start, I'm going to move into another two-part question and you mentioned some of these I know we've discussed this beforehand and you have lots of fantastic points here but we talked about getting that hand off and a lot of that hand off for you was very focused on the patients, home medications and also the patients medications that were administered by the paramedics while in route or on scene. Where do you see similarities and differences in the emergency department pharmacist world versus that of a paramedic when we're considering medication administration medication choice? Because really that is something we want to hammer home this year at MCHD I'm going to say this a hundred times but we really want to focus on medication administration safety and you know as an expert where do you see similarities and differences there as far as how we choose the medication, how we draw, how we administer in the truck versus in the ED. Yeah I think you bring up a lot of good points there. I think that you know unfortunately we've all probably seen a hand off that could have gone better on the ED side where you know you're talking about the paramedics are sharing a lot of like really valuable information with the team and for whatever reason it's chaotic there's not enough staff there's not somebody to record the information. We're trying to stabilize the patient you know while we're receiving hand off and so a lot of times there's a lot of room for improvement in those those handoffs on our end and so what I what I usually do is I try and listen as best as possible in the past when I was like a student and trainee I worked down a lot of what the paramedics shared and I've definitely been somebody who's chased after the paramedics after they are like on their way to the truck and being like wait you you told the team this and they don't you know remember you know whatever detail it might be from from the pass off and so I think that you know a lot of the like the comparisons between administering medications and the emergency department from like my perspective and then like from a paramedic perspective or it's kind of like same mission but different constraints so like we we both have to make a lot of rapid decisions we both have to deal with high risk medications we both are you know really in need of repeatable easy processes that need to be kept simple and easy to follow so that you know they can be they can be done safely safely I think what's obviously different is the environment you know in the field you may be administering medications on a moving truck or in an environment that might be less than safe or secure or what have you for the patient. There's not as many medication systems in the field. I know that MCHD does a great job with implementing a lot of protocols and trying to make them easy to follow and easy and easy to understand. But there's also not as much monitoring, you know, with they're usually just being like a paramedic and an EMT. There's not as much ability to like monitor a patient for response or what have you. And I think that that's all just the limitations that we have to accept. I think that what's important is that we work together to design systems that make the right action, the easy action. And I think that that is what so much of being a pharmacist in the emergency department can do is we can provide, you know, that second check that you were talking about that kind of like level of safety or the monitoring that sometimes won't be done by others. And so I think that those are some of the similarities and the differences. - Yeah, I think speaking to my own experience there, that safety unit that y'all provide, you know, second balance extra is so helpful when we're in, you know, a critical trauma situation, code situation or two of the biggest ones where there are, you know, multifaceted processes going on from a procedure to monitoring, to medication administration, to consultant communication. And it's all there and it's in here. And, you know, you bat 95% and you forget one dose or one medication or one protocol specific piece and having y'all really over my shoulder in my ear to say, hey, did you want to give this? Or is that really the route? Or is that truly the dose? Can really be a godsend sometimes and to the medics and the EMTs on the truck, there's only two of them. And especially in a situation where somebody's driving, there may be only one of them. And so environmentally, you lose that check and balance. And so to your point of designing systems and, you know, the medics are here at MCHD or are probably sick of me talking about utilizing our dose support and our protocol app, that's the reason behind that is to give you some of that backstop because no matter how good we think we are with memorizing doses and routes and protocols and I know our medics out there are, you know, excellent at that. None of us is about a thousand. And so having safety nets in place or just the key to patient safety. And so designing that system, you and I are in the same boat. That is absolutely something that we try to do and think about every single day. So on that note, you know, accepting limitations of our environment and the truck are on the scene and the trailer on the roadside, all of these spots that are markedly less controlled than the ED environment. What are some simple tips that you would give medics when trying to reduce or consider reduction of medication error? - I think it's all about standardizing, simplifying, speaking clearly. So I think that the first and foremost thing that we've kind of touched on a lot is standardizing, you know, making sure the protocols are good, they're easy to follow, they're making the easy way, the right way, right? You know, you want to follow the kiss method. My professor in pharmacy school always said, keep it simple, stupid. (laughs) But he really instilled in me that, you know, these protocols that we follow have to be easy to follow because that's gonna be the main thing. But I think other than that, make sure that we're saying the dose and concentration and the volume out loud, you know, whenever appropriate. One example that immediately comes to mind about, like, concentrations and dosing and things like that is this notion of a dirty epi-drip. And having practiced in many different parts of the country, a dirty epi-drip means so many different things within hospitals in Houston, within different areas in Houston, within different parts of the country. And so I think that being able to communicate what you want via like the dose, the rate, the concentration is really important. Like, many will say like a dirty epi-drip is like an epi spritzer. That's another lingo that I've heard. - Oh, I know, I'm making you cringe right out. Make it shot into like a leader bag. And so I think all of those things are should fall into the way of the past, you know, in 2026. We're hopefully starting a new year. Meds should have, you know, the right dose and labeling and everything like that on there. I realized that there are often many, many constraints in how critically ill a patient might be in the field. But making sure that when we're passing that information off to the people who are going to spend maybe like five-ish minutes with the medic team and then have to rely on the information that we got during pass-off, all of that information is really important and not like relying on lingo. I think that another really important thing is not being afraid of a double check when you have one. There have been many times where I'll draw up like a critical medication during, you know, like cardiac arrest or so. I mean, it doesn't get more critical than that. And I'll pass it to the nurse and say like, this is this medication at this dose. How many mils is in here? And they'll be like, they'll look at it and they'll say like, oh, there's three mils in here. I'm like, okay, great, that's how many mils I drew up. So it's like, I've been doing this now for nine years. And I'll still not be afraid of having a nurse double check me or having a physician double check me on something that we can't really afford to get wrong, you know. I think that things that MCHD does well is having like cognitive aids for various things in their protocol, especially with pediatrics, all kinds of dosing support. Having standardized concentrations for the drips and things that they'll allow for. I think other things that can be helpful are, I'll hold on that for now. But yeah. - I mean, there was so many excellent points in there. And we talk about, you know, the five rights, six rights of medication administration and talk about those on the podcast before. We talk a lot here about closed loop communication and verification, but not being afraid to be overly precise and to nail that confirmation. Those are two, just a lot solid bedrock foundational key points that we just have to own, I believe, especially in the field because of all those limitations that we talked about and not be afraid to be exact with the dose, the drug, the concentration and make that just habit. And sometimes, you know, things I've been guilty of when I listen to you talk about, you know, these different, you know, learning points is to try to pick and choose only the critical meds in the critical situations. And that to me is really a dangerous spot or a spot that's just fraught with pitfalls. And that is, it really has to be part of your practice in every single situation in which you give medication, whether it's Zofran or Arachuronium. If you're putting those habits into place and you're doing a MedCheck verification, you're verifying concentration, medication, dose and route every single time, regardless of whether you think that this is a critical situation or not, that makes it burn into your habit. That makes it a true habit because if we try to pick and choose inevitably we're gonna be wrong, I believe, and then that's when mistakes occur. The other piece that I see over and over in our cases here at MCHD is, the patient is critical, but the urgency to give the medication should never outweigh the need to give the medication correctly. And that is way easier said than done. But even let's take a cardiac arrest situation and we're talking about giving epinephrine, which as you know, and I know, that's epi's one that gets mistakes in and around it over and over and over again. If we're talking about, you know, Q2 minute, Q3 minute pulse check and a repeated epi dose, would we, is it really gonna be patient and impactful to wait 15 seconds, 10 seconds for the verification that's needed rather than give the wrong dose or the wrong route, especially in, let's say, a pediatric situation, I believe that every one of us would take an extra 10. 10 seconds for a double check or a triple check even as opposed to a risk and a rush and an incorrect dose. And on that note, speaking of that, let's delve into some of the more common and maybe also juxtapose with the most impactful medication errors you've seen in the emergency department because to the medics out there listening, I can tell you with a lot of experience in the ED, paramedics and EMS aren't the only one that makes medication errors. They happen across medicine. We're never going to get to zero. I think it's worth saying that this is always going to be a part of our practice. What we want to try to get to is a safe of a process as we can have safe habits and minimization. So hit some of the more common medication errors, Kevin, and then maybe a couple that were really impactful that you've seen in your career. Yeah, I think that you bring up a bunch of really great points, especially with the five rights of medication administration. I think that usually the breakdown or the cause, maybe not the cause of the med error, but one of the five rights is involved heavily in the five rights of medication administration. And I know we all kind of cover those and beat those over our heads, but they are very important. I think one of the most interesting or impactful medication errors that I've seen in my career was pertaining to epinephrine. It was a patient who came in with stroke-like symptoms, and we took them to the CT scanner, and we gave them iodine dye. This has been a number of years ago. They began having an allergic reaction, and we wanted to give them epinephrine. And the epinephrine was, instead of giving IAM, it was given IV, and then the patient developed a stemmy on top of their very real stroke. And so they had a stroke and a stemmy that we gave them at the same time. And so that was a pretty rough medication error, but you'll know that that involved our five rights of medication administration right route. So making sure that we're giving the epinephrine via the right route. There are a number of other medication errors that I see though on a very regular basis. I don't want to say daily, but maybe daily. And most of the most common ones I see are dealing with patient weights. You know, we'll commonly discuss patient weight in pounds, even though almost everything that I can think of, especially related to medications are dealing or pertaining with patient weights and kilograms. Yesterday, I had a patient who was documented as 180 kilograms, and he was really 180, or he was really more like 160 pounds. And so that translated to about 100 kilograms off. And so he was going to receive like way, way, way more anoxoparine than we had intended, which would put him at risk of bleed. But I think they're usually like medication errors or usually some sort of breach in communication. Other ones that I see commonly are calling things by brands when we should be using generics. And I know that that's such a pharmacist thing for me to say, but like things like Cardene versus CardoZym, those are two very different drugs. And I've seen them actually be given in certain situations where we meant one, but we needed another. And so then we're trying to figure out, well, we gave this patient a lot of tyazam instead of an acardapine. Now what? And so other things that I see are things like adenosine and atropine being used interchangeably. I fortunately have not seen adenosine given when we wanted atropines. So that's good. But yeah, I mean, these medication errors are out there. They happen with good frequency. A lot of the things that I see in the emergency department as well are when we document things in a note because we think that they're being given or that they have been given, but we didn't look to see if they'd actually been given. That's more on like the physician side to pick on you all rather than just our nursing and paramedic colleagues. Yeah, I mean, we could talk all day on medication errors. Now there's several good ones in there. I'll start with the last one you hit on and that's one that I deal with all the time is that, you know, the paramedics are playing the role of physician, nurse, and pharmacist at the same time, making their job exceedingly difficult back to that tightrope analogy. And, you know, I enter the orders and you and my nurse colleagues conspire to enter the PICSIS, which I cannot enter, to make that medication administration happen. But it is absolutely your correct incumbent upon me to make sure that if I'm documenting that X, Y, or Z was given in assessing efficacy treatment results, how the patient responds, I got to make sure it was given. And sometimes I've been totally guilty of, hey, is that patient gotten the nibs yet? What's going on? And then it was never entered by a physician. That's me. So, you know, making sure that the chain of communication and the actual orders that set that communication in action actually happen is something that we have to deal with in the hospital. Probably a little more than the medics do. Sound-alox, you hit cardism and cardine. It's a lot easier if you say delta-ism and macardapine. They don't sound quite as much alike. And if we want to lower the rate or we want to lower the blood pressure, we need to get that one right. Start with the same letter, atropine and adenisin. That's something that absolutely is an issue for us in EMS. And, you know, I really want to close with something that you started with initially. And I believe we all sometimes can take a little offense to, but I believe it's a key to my practice in a mercy physician. Your practice is a mercy pharmacist to our nursing colleagues, to the paramedics in the AEMTs and the EMTs on the truck. And that is to create processes that are as simplified and replicable as possible. That is not equivalent to dumbing anything down. That's trying to, that is trying to clarify. And to, there's no reason to have complexity for complexity sake. That is, to me, boneheaded at best. So I really believe if the listeners take one thing out of our discussion today, it's that making things clearer and understandable and repeatable from a process standpoint, that should be everyone's goal. And that's going to make everyone's practice no matter where you're at in the clinical medicine continuum system of care that we're talking about. Your patient risk is going to go down, your outcomes are going to improve and you're going to have less air. So I, I couldn't be happier to hear, hear you say that. We've got some other specific emergency department pharmacy questions that I'd like to get into, but we're approaching on 30 minutes. So we're going to have episode one and episode two, just spoiler alert to the listeners. But before we wrap this episode up, Kevin, is there anything else you'd like to leave the listeners with? No, I think that, that pretty much sums it up. I love that you, you talked about the importance of simplified processes and to, since we've picked on everyone from nurses to physicians to paramedics here, I think pharmacists are very keen to, you know, love making a process. And I think that when we're so involved in making it, we can't really see how difficult or nitty gritty it's becoming. And I think it's always important to rely on your colleagues, especially like your interdisciplinary colleagues to review things like this and say, like, how easy do we think that this would be to like repeat in the field or to implement in the emergency department? And I've definitely had colleagues from nursing to physicians to whoever take a look at things that I've put together and be like, oh, this will never fly. So I think it's just really important to continue to work together and serve as that second check for your colleagues. And user feedback, you got to have it because the best laid plans and when you put it in the back of the truck with a thrashing patient can be difficult to replicate. So the MCHD listeners out there, y'all know that you have access to Department of Clinical and to myself, to Dr. Deepas Kwali, because we may think through a process just like Kevin may think through the process as an ED pharmacist, but if the nurse and the physician out there at bedside can't enact it, replicably, it doesn't matter how well thought out it is. So I think that's a great, great point to leave on. Kevin, thank you for joining us today and providing your expertise. We value our safe reporting culture at MCHD more than anything, but we also know that we have room to improve. And so this is far and away, not punitive or negative in any way, shape or form. This is a conversation so that we can listen, think through our day to day processes, try to make improvements on a micro scale and see how that blooms and grows out into the care we provide the patients here in the county. So as always, thank you for listening. If you have questions, ideas for future podcasts, feedback, please email us podcast at THD-HIFT-X.org. Please leave a like or a review, follow us, subscribe wherever you listen to podcasts out there. We appreciate everyone who listens and as always we'll be back again with a new episode soon. This podcast was brought to you by the Montgomery County Hospital of District, Texas, production and editing by Andrew Adams. Questions or comments which are always welcome to be sent to [email protected]. Make sure to subscribe above to keep updated to all our future castes. Music, copyright, heavenmacloud and compotec.com licensed under creative commons by Attribution 3.0.