By Holly Drone
When it comes to administering medications in the prehospital setting, emergency medical professionals often have to use some ingenuity to confront challenges. Just like everything in EMS, there are situations we face on a daily basis (e.g., strokes, cardiac events, etc.) and then there are the wildcards. While our training prepares us well to handle those common situations, it鈥檚 the complex medication scenarios that create a need for a confident and creative expert.
That鈥檚 why in early 2023, Hennepin EMS (HEMS) created an official pharmaceutical consulting role in the field. For years, HEMS leadership had observed how EMS professionals would informally leverage the expertise of a clinical pharmacist in the ED setting, seeking guidance on everything from logistics, like crash-safe storage and dosage best practices; to helping identify efficient and cost-effective drug alternatives amid shortages or limited availability. The recognition of and response to this need and opportunity in prehospital care has ushered in greater understanding of the nuances of the prehospital setting and is filling a critical gap in collaboration between first responders and local hospitals.
And it鈥檚 a model that鈥檚 proving beneficial for all involved: from empowerment and support for first responders through innovative drug use and dosing, procedures, ease of delivery and space utilization, to a less-burdened hospital care team, and enhanced safety and dignity for patients throughout field response and what follows. As HEMS has observed in service to Minneapolis and 13 surrounding communities, involving clinical pharmacy in prehospital care can significantly level-up our standard of care.
Following are three benefits of clinical pharmacy in prehospital care.
1. Breaking down barriers and finding shared language for collaboration
Imparting procedural change can be a challenge when EMS professionals and pharmacists in the hospital setting don鈥檛 have a shared understanding of what the procedure looks like outside of the hospital setting. Whether it鈥檚 a new protocol that will affect hospital care or if it involves a medication dosage or use, often, pharmacy departments are very risk averse 鈥� and usually for good reason.
At HEMS, our clinical pharmacist is a dedicated resource who can bridge the gaps between status quo hospital pharmaceutical care and in-field emergency response, two incomparable environments. As a clinical pharmacist, I benefit from knowing the context of how medications are administered in the field and stored in an ambulance. This enables advocacy for creative, safe and, often, more cost-effective solutions to real challenges.
What started as an inquisitive relationship between paramedics and a clinical pharmacist in the ED setting has evolved into an integrated care team, including frequent ride-alongs with paramedics, meeting regularly with the medical directors, and hosting open-door office hours at HEMS as we collaborate on process and quality improvements.
2. Enabling creative, safe, cost-effective solutions to unique EMS challenges
Where a hospital or ED might have hundreds of medications readily accessible at a given time, an ambulance is typically stocked with only about 30. The challenges that paramedics face can be vastly different from those in a hospital setting.
A big part of a clinical pharmacist鈥檚 role in prehospital and emergency care is to identify creative solutions that empower EMS professionals to be more efficient and effective in emergency situations while still maintaining standards of care and safety. Some of my counsel comes into play when there are drug shortages or stocking limitations and we need to identify the most appropriate alternatives.
Creative collaboration is also required given the space and storage limitations that paramedics face. Some medications need to be temperature-controlled, limited in their light exposure, and shelved in a crash-safe container so they don鈥檛 move and break when in transit. Even medication hanging on a hook while transporting a patient must be break-proof and have some protective mechanism for both the paramedics and the patient. An example of an effective, efficient innovation HEMS developed in this arena is in our use of tranexamic acid, a medication that鈥檚 used for massive bleeding. Previously, we used a version that required vials of the drug and a saline bag drip. The process was cumbersome, requiring considerable time, space, energy and extra needles. In learning it was a significant challenge for HEMS medics, we worked to find a pre-made solution that was effective, easier to store and administer, and financially prudent.
3. Prioritizing efficiency and advancing public health
The role of clinical pharmacy in the prehospital setting can bring more efficiency in the field, helping to reduce some of a paramedic鈥檚 mental load and allowing them to be more focused and expedient in potentially life-threatening situations. For example, several of the medications administered are dosed in milligrams per kilogram demanding quick calculations and estimations about a patient鈥檚 weight, without always having a convenient weighing system. I鈥檝e been able to consult on medications that can be standardized for almost all sized patients.
This role also supports HEMS鈥� priority of advancing public health. Beyond just addressing the emergency, we鈥檙e identifying ways that we can support the long-term outcomes for the individual we鈥檙e responding to and their families, working to ensure a safe and supported transition to hospital. HEMS was one of the first agencies to roll out prehospital risperidone, an oral medication to treat agitation that we鈥檙e using in place of intramuscular or intravenous (IV) drugs for patients who are mildly-to-moderately agitated on the scene. We鈥檝e given hundreds of doses and had a lot of success helping de-escalate patients in a safe way that doesn鈥檛 involve needles or physical restraints. Offering the patient something that they decide to take can help establish their trust with the paramedic and help them calm down. By the time the medication kicks in, is about the time when patients arrive at the receiving hospital, more smoothly transitioning from prehospital to emergency department care.
| More: Goodbye, pencil whipping: Reimagining drug tracking compliance
The future of pharmacy in EMS
The integration of clinical pharmacy more fully into emergency medical services has unlocked so many opportunities for collaborative and innovative problem-solving for our service. We believe there is so much more we can do creatively as we think about how to use medications in a different way and in a different setting 鈥� whether for patients at home or in an emergency setting, in a clinic or in a hospital. Pharmacists can play a huge role in that.
When we break down the silos that we work in and seek to better understand the unique applications that we are providing care in, we can better meet the needs of the populations we serve. And that鈥檚 something that every community can benefit from.
ABOUT THE AUTHOR
Holly Drone is a clinical pharmacist in emergency medicine and emergency medical service at Hennepin EMS in Minnesota. Since her addition in 2023, she has helped Hennepin EMS bridge the gap between pharmacy and EMS. She not only understands the breadth of pharmaceuticals available but also the operational challenges of providing care outside of a hospital setting.