In this great podcast Justin introduces the principals of pharmacology that have served him well over the years and have done far more for him than simply keeping him out of trouble. He also introduces Brad Morgans CRNA who is a wealth of knowledge and experience in not only combat and austere theaters but also in working with and relating to, SOF medics and the challenges we face. This is the first with more episodes in the series to come so listen, download, read and understand the principals that, if heeded, can make the lives of you and your patients’ safer and more comfortable. These principals should challenge you and spur you along to learn more about the drugs in the magic, locked narc box and the effects they will have on your patient. If you are a medic and haven’t had the chance to push the same drugs you carry in a controlled setting, what can you do to help make that happen? If you are a medical director, have you done everything in your power to give the medics who practice under your license (without your oversight) the opportunity to see the effects of these drugs first hand? If nothing else this should help spark some good conversations between you and keep you on the same page. Add your comments to the discussion below, but first listen to the show…
Check out the show notes and handout below…
Pharm Principles for SOF Medics
- A bad memory is better than no memory; the patient doesn’t get anything until his vital signs prove he can handle it.
- You are expected to make pain manageable; not take it away completely – this would be total anesthesia. You have to make this clear to your patient. Know the difference between sedation, analgesia, and anesthesia as well as which drugs will work to those outcomes.
- If you are going to sedate a patient, acknowledge that you will lose mental status as a vital sign. If you find yourself about to give an aggressive dosage of medication, take a minute to think. Ask yourself how it will complicate your situation, and then decide.
- “Cookbook” formulas are only starting points. Every patient is unique and requires a tailored approach. Although we recommend that you have “cheat-sheets” stored with your medications, recognize that these are to guide you while under stress, not as a “one-size-fits-all” approach to sedation and pain control.
- Titrate to effect. Be patient. Wait for the medication to peak. If you don’t know the time peak effect for each of your medications, see number 9.
- Your first experience pushing controlled medications should not be in a crisis. If you carry the medication, you have an obligation to 1) undergo training by a currently practicing anesthesia provider, and 2) to administer the medication under supervision during real cases. A Powerpoint class does not qualify you…
- Performing procedural sedation on your own is a big deal. Don’t put unnecessary pressure on yourself; consult a specialist if possible. Assemble your equipment, devise your plan, and attempt to brief that plan to a higher medical authority. Performing sedation will likely be one of many “big deals” you are dealing with under stress. Consult – it’s the standard of care.
- If you are going to sedate, you need to have MSMAID covered. Monitor, Suction, Machine, Airway, IV, Drugs. A professional will have access to some form of these items if they are going to sedate. A BVM can be your machine, a pulse ox can be your monitor, but you must have these items covered in some form before you sedate.
- Know all your drugs inside and out. Be able to rattle off the class of drug, indications, therapeutic dosages, half-life, time for peak effect, contraindications, adverse effects, usual concentrations, pitfalls, and your personal strategy for dilution and titration to effect.
- Take care of your medications – if they fall outside temperature range, they may lose efficacy. If they are stored in an extreme temperature, hot or cold, (such as during a gear shipment) seek to replace them ASAP.
- Avoid IM administration if possible. It is often extremely variable especially in a trauma patient who is not circulating well.
- A sedated or intubated patient has a “watcher” at all times. This person must be trained to read your monitors, listen to breath sounds, re-confirm tube placement, and look for “red-flags”.