Episode 193 - What Can EMS Learn From An Emergency Pharmacist? - Part 2

[Music] [Music] Hello everyone, welcome again to another edition of the MCHD Paramedic Podcast. This is Dr. Casey Patrick and we are back for part two of what can EMS learn from an emergency pharmacist? We're lucky to have Kevin Mercer with us again on the podcast to talk about his thoughts about medication administration in the field and the interaction between the emergency department pharmacist and EMS. And real quick, Kevin, you've been on the podcast before. So, you don't have to belabor the points for the folks that may be listening out of order a little bit. Before we get into our questions, tell the listeners quickly about who you are and your current roles and we'll roll into some questions that I've got that we didn't get to hit on in episode one. Hey everyone, thanks for having me back, Dr. Patrick. My name is Kevin Mercer. I'm an emergency medicine pharmacist and assistant professor. I teach at the University of Texas at Austin College of Pharmacy. I coordinate an emergency medicine pharmacotherapy course. And then I'm an emergency medicine pharmacist at HCA Houston Healthcare in mostly at Kingwood Medical Center, but I have worked in various roles in the Houston area. Thanks for having me. Kevin and I sit beside each other every now and again at HCA Condrow. And that's how we met and talked medicine and MCHD protocols and how some of our medications make Kevin really excited and some of them maybe made him a little bit nervous. And so that led into further conversation and the more we talked the more I realized that our listeners absolutely would love to hear from a pharmacist content expert, especially an emergency pharmacist. I actually learned that there are pharmacy residency matches in episode one. I knew that Kevin did further training in emergency medicine. I didn't realize there was actually a residency match on the pharmacy. I'm sorry that you had to go that through that mess just like I did. It's miserable. But this is a really excellent opportunity to really have a good cross disciplinary conversation. And we're going to change gears a little bit from episode one where we talked a lot about medication air specifics and how we can help to reduce those and the value of simplified and well designed processes to talk a little bit more clinical. And this is a piece that I don't know that all our listeners are aware of, but you're a clinical wizard when it comes to the care of a lot of our sickest patients in the ED and y'all are super valuable to me as an emergency physician. Y'all aren't just their dispensing drugs. You're helping think through differentials and pharmacotherapy in a really in depth way. And I think that's part of go down that road a little bit Kevin, who are your favorite patients to care for in the ED and y I talk a little bit more clinically as far as which ones do you really like to treat and you know describe how your involvement with those patients gives you gives you some joy. And for all of those compliments, Dr. Patrick, it's really great to sit down and talk with a physician who really understands our background and kind of the value that we bring to patient care and the decision making process and all of the things that go into that. I think some of my favorite patients to care for in the ED are to be very pharmacy biased or the ones that we can give a medication to and then things are, you know, getting better very quickly for them. It's very instant gratification. So I definitely have taken care of patients with like in a full axis before where the patient was stung by like a bot fly and we were about to like crack her in the hallway as we were trying to run her to a room and I ran to get the epinephrine and the steroids and all of that from the pixas and we gave it and she immediately was like I have to get out of Florida of like these things are trying to sting me and you know she went from you know nearly dying to trying to book a plane out of Florida so she wasn't stung anymore. I really am very passionate about stroke. Both of my sets of grandparents have you know experienced a stroke and ultimately you know it was what was there. You know cause of going down that path but that kind of hits home to me still caring for patients with stroke and I think that that is a good place for a pharmacist to really embed themselves because it's so protocolized it's so process oriented but there's still a lot of things that are going to happen. So I think that's a good place for a pharmacist to be able to do this. I'm the one to kind of be like, oh, this patient is really a candidate. I called their, you know, insurance or their nephew or whoever. And we got record that they were, you know, seen normal at this time where they don't fill a picks a banner. What have you. And then I feel like the ER pharmacist is very commonly involved in all the zebra's in the emergency department. I've participated in cases before where, you know, we call a patient for their culture follow up and we can't get a hold of them. I see that they have like a cryptococcal meningitis, which is super rare to see for a patient in the emergency department. And so I called for a wellness check and this patient was like, obtunded at home and was truly did truly have cryptococcal meningitis. And I was definitely a zebra. I've seen cerebral malaria before and we've had, you know, trouble getting medications like the Artemis and our testinate formulations from this CDC back when they had to be dropped ship from the CDC and this patient's wife was like, well, we have these medications we bought in Kenya. And so exactly the medication that we needed and so I had to work through the processes of proving that I just love being able to find the missing piece in a patient's care and really apply it and being the person to kind of help make all those things happen. We are pharmacists, we're really relied on to make things happen reliably but and correctly and quickly and I think that we can all really make those impacts and in real time in the emergency department. You hit on immediate gratification and I want to just expand on that a little bit from from my perspective as an emergency physician. I can speak for a lot of paramedics out there. We all love that to be able to give I mean, anaphylaxis is a great example because it's quick and it's impressive and it can be truly life saving time sensitive, all the sort of the things that we talk about as being desirable. And it hits all those but also you're giving epinephrine which is like we talked about in the first episode the more basal active the more high risk a drug is the more we have to be precise and giving that epinephrine IV instead of I am in that situation can be disastrous from a rhythm standpoint from a cardiac impact standpoint is huge. And so yeah, we want to we want to get the epine quick and we know the anaphylaxis is deadly and we are in a rush that it hits sort of all of those buttons but we have to be precise we have to give it I am we can't give it I V we've got even bigger problems and you've created from a critical situation to a deeper hole to try to dig yourself out of. So I love those two I know we've talked before about some of our MCHD protocols and and I know that you've not mentioned my favorite patient yet I thought you were going to get there but we can get there in this question. And that is and we've you know obviously have different risk tolerances and risk approaches and considerations of doses that we use in our protocols at MCHD and we've talked through a lot of those you know in offline discussions but which MCHD protocols have most peak your interest because not all of these did you and I talk about before you receive the first patient that received dose X Y or Z of a certain medication for a certain. Protocol and we try our best here to communicate our protocol changes and updates with our hospital partners but we all know how that trickle down is not 100% in that you know that email may never have gotten to you or if you're like me that email may have gotten deleted or not red. Certainly so talk about some of the protocols that you've seen that you like the most or maybe some of the ones that made you nervous because I believe that my patient my favorite patient is on there I think. Yeah so one of the things that I've been most impressed with MCHD protocol wise protocol wise is is they're treatment of patients with scape or sympathetic crashing acute pulmonary edema, sometimes called flash pulmonary edema, just depending on who you ask. I think that the provision of the IV nitro glycerin at the doses and the rates that are provided by MCHD is really progressive. So I believe they allow for up to a milligram or a thousand micrograms. And I remember the first time I heard a paramedic getting pass off to the ED team for this patient escape. And they were telling us what they gave. And they say, oh, and we gave a milligram of nitroglycerin. And I said, you gave a milligram of nitroglycerin or like a microgram of nitroglycerin. And the paramedic was like, oh no, we gave a milligram. And I was like, wow. And so like the patient was pretty much already resolved by the time they got to the emergency department. And I think that's just a testament of the, you know, like that the right kind of protocols and safety checks in place that it can really truly benefit patients. I patient ended up being discharged from the emergency department. And I think, you know, going along with like the instant gratification, I love treating those patients as well as I believe Dr. Patrick does. And we had one yesterday in the emergency department where I kind of got to teach the nurse and the medical resident. Like what we're doing, what kind of like bi-pap settings even we need, because we had the patient on like bi-pap of six. And it was like, we really needed, you know, target like higher, like 10, 12. And they were also surprised that a pharmacist knew what peep was and all kinds of things like that. And so while getting the nitroglycerin ready and on the pump and pulling up the bulls and all of those things. So yeah, I mean, that's been one of the most progressive protocols that I've seen from MCHD. And I think that is something that could be replicated by other systems. Yeah, progressive is always a word that I am leery of. I think it's used a lot. NEMS, everything that's progressive is not necessarily validated or safe. Use the cliff analogy that I can be very progressive and move forward and progress myself right over the edge of the cliff. And so I believe that with protocols like that, and the listeners know this. And I think the listeners know that taking care of flash pulmonary edema is my favorite patient. It goes back to my training and one of my mentors and has been a group of patients during my career that I've really enjoyed taking care of and feel like that early volume redistribution is absolutely vital. And if we can, you know, Vinodilate and dilate arterially that we create more space and more space means less fluid in the lungs. And then we have time to assess volume status and consider diuretics and make sure that we've got correct non-invasive positive pressure settings, all those things that you mentioned. It really buys us time up front and gives that patient a chance to not be intubated, which is not where we want to go with them if we don't have to. All that said, 1,000 micrograms of Dr. Gosarin is a big deal. And so from that standpoint, we pride ourselves here at following these outcomes very closely. Some folks ask, I'm not an academician or a researcher by trade, but I believe that from our standpoint, it's a clinical team. If we're going to put some of these more advanced protocols into play, it's incumbent upon us that we have to track these patients and their outcomes and their safety status up to the point of peer-review publication, because that's what EMS and EMS medicine and science deserves. Because that's something that we can do here in Texas, based on delegated practice. And we love that as a medical direction team and a clinical team here at MCHD. But we also take the risk and the mueness of these protocols really, really seriously. And so I think that for the listeners out there to know that an ED pharmacist was like, well, with 1,000 micrograms, yeah, we knew that was going to be the case. And that's why every one of these patients had been followed for the last five, six years or over along this protocol has been in place. And we did not take it lightly in any way, shape, or form. But I do believe that the evidence supports this treatment. And that they're-- Sure. --interficient. And my surprise was more so that I just wasn't expecting that for me in this rather than in the emergency department. And so yeah, to your point, no, it's absolutely indicated and appropriate in these patients. I was just kind of taken by surprise that that's how we could-- we could be doing it in Conrad, Texas, right? Well, I could be perfectly honest with you. You're probably not aware of this. I was-- that pushback was not towards you. There has been some recent EMS discussions elsewhere. I can only imagine how difficult it was to get that protocol through. Around this diagnosis. And we take it very seriously. And we feel like we have the data to back it up. I'll just-- I'll leave it at that. But you hit the nail on the head. The immediate gratification for those folks is very, very-- it's fulfilling, for sure. And these patients are not terribly common. This isn't every volume overloaded patient who has a pressure of 190 and a respiratory rate of 12. That's not the patients we're talking about. And I think that you are well aware of this when we talk about the patients with sympathetic surge and to kit me a tachycardia diaphoresis. These patients are the patients that are in extremists that we're targeting. And I know the listeners have heard this till they're blue in the face. But I think it's worth noting there. We talked in the last episode. We talked some offline about the value of communication. I'm going to shift gears a little bit. And every step in the continuum of care and a critically old patient, it starts with the 911 call. And our call takers and dispatchers here at MCHD. And then oftentimes our first responders and our fire partners show up. And they transfer the patient to our EMS crew. And it's some combination of paramedics, and DOR EMTs or AMTs. That patient's brought to the hospital. They're cared for in the ED by nurses and docs and pharmacists who then emit the patient to maybe the ICU or the OR or the floor. I could keep going. But there's so many steps in the game of telephone. The most important pieces there are that patient handoff. And that's also a danger zone. Because as you know, things get lost there. So speaking just to the EMS handoff in the ED, and specifically your role as a pharmacist, what do you wish every medic would include in the handoff to the emergency pharmacist and or the ED team? Where can we improve there? Where have you seen successes there? Talk a little bit about that. Yeah, I think that's a great question. And I mean, probably this isn't a super surprising answer. But if you just give me the dose time response of the medications that you've given, I can really do a lot with that. And so medication name, your dose and concentration, avoiding the jargon kind of like a dirty, ebbedrip or an epi-spitzer or whatever it might be. And then the response, if the patient got better or worse, or they coded or they didn't or what have you, I think that that's really helpful. But I think also recognizing that the EMS pharmacist is really trying to look at things holistically and be kind of like a second set of eyes for the provider, but just like from a treatment and medication standpoint. Like we're very interested in what the past medical history is or how they presented and like what their, you know, vitals, like notable vitals or any findings might have been when you saw them versus after you started treating them. I think a lot of the times, I'm trying to think about the questions that I specifically ask EMS when they're providing handoff. And a lot of the times that's about route, like we'll talk about how much naloxone was given, for example. And like EMS will say, like, oh, we gave them so much naloxone, we gave them 8 milligrams. And you'll find that a pipe in will say, well, like how did you give it? And they'll say, like, oh, we gave it intranasally, I am. I'm like, OK, well, we can still, like, maybe it would be justifiable to try IV. I think that, you know, those discussions of route are really important in those cases. I think that including the, if there were any adverse effects to anything that you gave may have been beneficial or like, this happened. And so we had to pivot and give, you know, XYZ men. All of that's really important. I think that gets lost in handover in both directions, because I think the medics know that they give me, and they give you handoff in the ED. But then we're going to give handoff to someone else. So I'm going to give handoff to an intensivist or a trauma surgeon or a cardiologist. And I believe the point that you nail there that it's important for all of us, no matter what stage we're at in our. careers as emergency department clinicians. And that is you did something then what happened. I think so often, this, this, and this. Okay, what happened? I gave X dose of Adenisin. What happened? Did the patient cardiovert? Did they slow and then speed back up? Did you catch a rhythm strip? So I always try to simplify it as, what did you see? What did you do? And then what happened on the way? And if you can include those three things, and that's gonna involve, you're gonna have vital signs and subjective assessment of the patient, what did you do? Well, some of that's gonna be medication, some of that may be non-medication related, suctioning, positioning, some of the foundational, well, I support type things. And then what happened? And I believe that's where I, when I'm passing off to a trauma surgeon or cardiologist, when I'm in the medics role in this scenario, and I'm the one that's giving handoff, what happened when you treated the patient? Because that next, that's gonna determine the way that the receiver is gonna continue care. Or move a different direction. If I gave three nebs and steroids, and the patient's sats are worse, and the respiratory rate is higher, I'm probably gonna consider looking more towards something like scape, or towards pneumonia, or towards a pulmonary embolus. But if you gave them three nebs and steroids, and now they look like a million bucks, then that's, you're probably on the right track with obstructive lung disease, C-O-P-D, asthma, wherever we are, and I'm gonna continue that. So it's not just, I think you hit a really important point there. The ED pharmacist doesn't just care about the medications that we're given. They want the specifics, what medication, what concentration, what route, that's so key. And then, how do the patient react? Because was there an adverse event? Do we need to go away from a certain type of medication moving forward? Is it an allergic reaction? Is it a side effect? Those sort of things. So I believe that's really, really good reminders for the listeners. Anything else you wanna tag on there before we roll into our last question? - I think one thing that EMS does consistently well in my experience is all of the information that they're able to provide with, if they have a bag of home meds or something, I'm usually one of the first people to kind of dig through those and see them, but also in overdose situations, they'll tell me like, oh, we found these on the floor, or in the like sometimes they'll have a picture of the tablet, or they'll say like, oh, all of these bottles were found on the scene, and here's a picture of them, and these are the strengths, and we believe that they were like, you know, full based on, you know, what the family said. I feel like those situations, like everybody is very keyed into, this is really, really important, like information and details to be able to take in and jot down, and I think that as an ER pharmacist, I'm very interested in those details, and I can't really think of a time I've been disappointed by the information provided by EMS and those situations, and so that's always been a good interaction. - Absolutely been a lifesaver for me, more times than I can count in my career, you know, the bag of, I don't have a med list, well, you got the grocery bag over there, that's just, I can recreate the med list, and from the med list, I can get to most of the medical problems, even when they're altered, and that's a, it's a not full proof, but I can do some pretty decent extrapolation. One of the things that I will say that, if you and I can spread to our emergency department colleagues, and especially some of our hospital colleagues, something that you understand in the ED, and I know that I do as an emergency physician in an EMS doc, sometimes the answer is just we don't know, and sometimes the situation is just, it's undifferentiated, the patients altered, they were found down, and we just don't know anything. No, we don't know the last no, well, Dr. Neurology, sorry, I don't know it. And I think sometimes I see frustration from medics when maybe that grace isn't given as well as it should be, and I know that the neurologists sometimes are the ones from the last no, well standpoint that can get really frustrated, and we just don't know. But I've also seen my ED partners and emergency nurses get flustered with lack of historical information, and if it wasn't obtained out of neglect or laziness, and yeah, that's not acceptable. But sometimes, and I would say most times, it's just the fact that, you know, and now a woman called was made, the EMS team was in possession of the patient for 20 or 30 minutes, and no one knows anything, and the patient's got a GCS of eight, how are we gonna find it? And so I believe it's important to remember that sometimes EMS isn't gonna have the answers because no one does, and we're gonna have to be detectives just like the paramedics were, and continue down that road. Yeah, that frustration that might be felt by the team members in the ED is like speaking from experience. Like, if that occurs, I'm like, oh my gosh, I have so much to do right now. Like we don't have a history or we don't know, like when the last known well was, or like I'm just thinking of all the things that just got expanded, like we have to like now include this and are different, we have to do that. And I have like a million things that I need to go get or figure out or start or all kinds of things like that. And so I think that extending that grace to our EMS providers is really important because they've likely been dealing with the same stressors in the field. And yeah, it's just like kind of like welcome to the party. Welcome to the party. Yeah, my exam just, I've gotta do it all. And the Lombard punctures now on the list, every test that I was gonna order times three. So yeah, same thing for me, it's like everything just became more complicated and complex. And I've gotta consider a differential list that is markedly longer as opposed to left side of facial droop and arm weakness and leg weakness that started two hours before arrival. I can get a little more honed in on that case than the found down. So I would agree. And rather than complaining about the fact that we don't have the information, it's probably best for the patient for all concentrating on the difficulties that we're gonna have to navigate. So on that note to wrap up our second conversation here, I wanna thank you again for agreeing to join us and talk about your perspective as an emergency pharmacist. This has been just really excellent. Where do you see the biggest opportunities for collaboration? EMS and ED pharmacists, probably something that should be considered more. I've not heard a lot in discussion. I'm happy to kind of scratch the surface here. I know we've got some plans to utilize your expertise here within our service outside of the podcast. But thinking about emergency pharmacists out there across America and EMS systems, where can we collaborate better? What, where could we make those inroads and start that partnership? - Well, I think that one of the biggest roles for an emergency pharmacist in the emergency department is like providing that second check, providing that extra educational piece. And I think a lot of those things could be mimicked in the EMS kind of world. So I think that protocol alignment, assisting with protocol development, especially with regards to medications and high risk medications and when to give and how to assess for response and when we should stop doing what we're doing and start a whole other treatment pathway or something like that, really the nitty gritty of the pharmacotherapy. And with that could come, you know, like joint training on high risk meds, you know, how to prepare certain medications. You know, there's a lot of tools and tricks of the trade that I've actually gained from EMS and that I'm sure that we could kind of like share back and forth. I think that there could be, you know, good case review on, you know, medication errors. We've talked a lot about how medication errors are likely 100% unavoidable. And so I think that, you know, having a pharmacist review those kinds of things and see if there are any opportunities for prevention in the future, all kinds of things like that. You're still holding out hope that we can bat a thousand. You're a holomath hope that we can be perfect. I just think we got humans and we got tough situations and I don't mean to, and I say that lightly, I don't mean to excuse away and not shoot for perfection 'cause goodness knows that's where we need to go. We need to try to get to no med errors, but I just feel like in the world, and we've talked a lot about the EMS environment that it's probably gonna be impossible, but we need to get as close to zero as we can while still having a safe reporting environment. And I believe what you just said and very eloquently is that we need to value each other's perspectives and learn from each other's perspectives. And I think that you weren't just talking to the paramedics listening to the podcast with the idea of streamlining processes and looking at protocols. You're talking to the emergency physician, EMS physician medical directors as well that we need your support. Just like I needed in the ED, I needed in my EMS role as well. REMS role as medical. director. So I think that's I think you know learning from each other and learning from each other's expertise and health care shocker that's going to lead to better patient outcomes. So I love that answer and I think it's a great part great spot to wrap up anything else you want to add before we close up. No thank you so much for having me back on the podcast it's been great to chat with you all about all things pharmacy emergency medicine pharmacy medication safety if you ever see me out in one of the HCA hospitals or wherever and you're interested to talk about a medication or a medication error maybe you caught love to hear more about it. And for the listeners I've been doing this a while Cryptococcal meningitis think about it look for it sometimes in that off in CSF never had that one. It was definitely a unicorn yeah. Subrible malaria if you listen way back early on in the podcast I spent a summer in Uganda and I saw Subrible malaria but I had to go across the world to see it. So I have never seen that one in the states either so those are definitely a couple unicorns so I love both of those. As always y'all thanks for listening to the podcast subscribe like leave us a review wherever you listen to your podcast. If you have questions ideas questions for Kevin email me podcast at mchd-x.org. We appreciate y'all listening and we back again with a new episode soon.