Course Objectives”ž
- Describe the roles that patient medications can play in prehospital patient care.
- Discuss and apply patient medications in effective prehospital assessment and treatment.
- Identify patient medication educational resources, which are available for prehospital providers.”ž”ž”ž
It’s a busy day in your town, and Medic 1 is dispatched to assist police with a possible psychiatric patient, reported as disoriented and aggressive. The police report the patient takes Glucophage. Meanwhile, Medic 2 arrives at a church to assist a 70-year-old woman who fainted. She takes Lanoxin. Across town, Medic 3 is on scene with a 15-year-old girl who took a handful of over-the-counter Tylenol tablets. She’s asymptomatic and the mother wants to refuse care. At an assisted living facility, Medic 4’s crew is performing bag-valve mask ventilations on an elderly cancer patient who takes Lortab. Medic 5’s crew helps a 60-year-old chest-pain patient take his own nitro spray. The man also takes Cialis.
In each scenario, understanding the patient’s medication would enable more effective assessment and treatment during the emergency. But current EMT and paramedic training standards require little education on patient medications. This article attempts to partially fill that gap with an overview of common patient medications and a focus on their relevance to prehospital care.
Medications today
When surveyed, half of all adults report taking a prescription drug within the past week.1 Even one-fifth of children have taken a prescription drug within the past week. Although these percentages have been stable since 1999, there has been an increase in the use of multiple medications in the past decade. Ten percent of adults now report taking at least five different medications in the past week. These percentages are probably higher in the patient groups that need prehospital emergency care.
With the ubiquity of drugs now, it’s easy to overlook how recent a phenomenon this is. A century ago, many Ë™medicinesà“ were typically alcohol or otherwise ineffective. Only a few drugs used thenÆ’such as morphine, aspirin and digoxinÆ’are still in use today. Before the widespread use of antibiotics in the 1940s, many people died of infections that are readily treated now. Even in the 1950s, few useful drugs existed to control hypertension. When Congress enacted Medicare in 1965, a prescription drug benefit wasn’t thought necessary, reflecting the limited role of drug therapy in medicine.2
It’s a far different story today. In 2005, Americans filled more than 3.4 billion prescriptions.3 There are about 12,000 distinct prescription drugs declared safe and effective by the FDA and available for sale in almost 138,000 formulations.4
For high blood pressure alone, there are now almost 60 approved drugs.5 Two-thirds of physician office visits end with a medication being prescribed or handed out, with antidepressants being the biggest therapeutic category.6 These figures exclude over-the-counter drugs and unregulated Ë™dietary supplements.à“
As illustrated in the opening scenarios, the use, overuse and interactions of patient medications affect assessment and treatment every day in”žEMS systems. Faced with the overwhelming number and complexity of patient medications, EMTs and other emergency responders who try to become more knowledgeable may feel overwhelmed, like they’re drinking water from a fire hose. But a modest amount of knowledge can go a long way toward improving patient care.
Drug basics”ž
First, let’s go over a few fundamentals. Drugs are sold either by brand name or as a generic version. A company that develops a drug usually has exclusive marketing rights for three to seven years after approval. After that, other companies may sell their own Ë™genericà“ versions of that drug.
Brand names are usually capitalized, whereas generic names are usually not. Companies choose brand names, so the brand name is usually more memorable than the generic name (e.g., Lopressor versus metoprolol or Viagra versus sildenafil).
Newer drugs are usually better known by their brand names; older drugs are better known by their generic names. Generic formulations are therapeutically equivalent to brand names. If your patient says he takes Lasix, the prescription label may actually say furosemide.
Drugs are most commonly taken by mouth. A few alternative routes are also important to know: skin patches for nitroglycerin and painkillers; inhalers for asthma medications; sublingual tablets for nitroglycerine; and subcutaneous injections for insulin.
Managing drug therapy is a challenge for both physicians and patients. Four-fifths of seniors have taken prescription medication within the past week, with 29% of them taking at least five drugs.1 Over half receive prescriptions from more than one doctor, and 36% receive drugs from more than one pharmacy. Among seniors with three or more chronic conditions, half don’t take all of their drugs as prescribed.7
Moreover, the same medications can work differently for different patients, or even have different effects on the same patient at different times. Biological changes can make patients become more sensitive to drugs as they get older.5 Also, patients with kidney and liver disease can have much stronger reactions to standard dosages than other patients.
The development of new drugs, growing use of multiple drugs and population aging are likely to make medication management more challenging in the future; however, better electronic medical records and computer-aided prescribing may improve care coordination.
Relevance to prehospital care”ž
For emergency responders, patient medications can play into assessment and treatment in the following ways:
Clues to underlying diagnoses: The FDA approves each drug for specific indicated purposes, and many drugs are commonly associated with single conditions. Examples are Dilantin for seizure disorders, insulin for diabetes, and Singulair for asthma. In the first scenario, the presence of Glucophage should prompt Medic 1’s crew to ask about diabetes. The patient’s disorientation and aggressive behavior may be simple hypoglycemia, with no psychiatric illness present at all.
A physician, however, can prescribe a drug for any reason. About 20% of prescriptions from office-based physicians are for unapproved, Ë™off-labelà“ uses. Cardiac drugs, anticonvulsants and asthma drugs are especially likely to be prescribed off-label.8 Therefore, emergency responders should use the presence of specific medications as cues to ask additional questions about medical history.
Unintentional overdose: Many drugs are intended to help the body maintain homeostasis. Common examples are drugs that increase or decrease blood pressure, heart rate, blood sugar or thyroid hormone. Such drugs as insulin, warfarin and digoxin have narrow therapeutic ranges and are frequently implicated in unintentional overdoses.9Figure 1 shows that unintentional overdoses result in an estimated 225,000 emergency department (ED) visits per year, including 63,000 hospitalizations.
See April 2008 JEMS for Figure 1.
In the second scenario, the patient’s syncope could have been caused by an unintentional overdose of digoxin (Lanoxin), which slows the heart rate. Although this possibility wouldn’t change the prehospital care given by Medic 2, the crew should ensure that the receiving physician knows that the patient takes digoxin.
Intentional overdoses: In 2004, an estimated 5,800 people committed suicide in the”žU.S. by overdosing on prescription drugs and other substances, representing 18% of all suicides. (Firearms accounted for 52%.)10 In addition, there were 122,000 ED visits for drug-related suicide attempts.
Painkillers, antianxiety drugs and antidepressants are commonly implicated in intentional overdoses, often in combination with alcohol.11 Medic 3’s asymptomatic patient may have ingested a toxic dose of acetaminophen. Although the drug is widely and safely used, overdoses can cause fatal liver damage.12
On all calls, but especially on intentional overdoses, the emergency responder serves as the physician’s eyes and ears on scene, with access to information that the physician might otherwise not receive. Unless local protocol dictates otherwise, bring all available pill bottles from the scene to the ED.
Even if pill bottles are unavailable, it’s useful to bring remaining pills and patient vomit to the hospital, since ED staff may be able to estimate not only the volume and timing of total ingestion, but also the specific drug ingested.
Indications for prehospital treatment: A patient medication may provide you with an important tip for prehospital treatment. While Medic 4 is en route to a report of an elderly cancer patient who’s not breathing, the crew may assume this is a Ë™routineà“ code for a terminal patient. In fact, the patient may have years of life expectancy and simply overdosed on LortabÆ’a narcotic painkiller and respiratory depressant that can be reversed by nalaxone (Narcan).
Contraindications for prehospital treatment: In many states, EMTs can assist patients with their own drugs, including nitroglycerin to dilate their blood vessels when they experience chest pain. Drugs for erectile dysfunction, most famously Viagra but also Cialis and Levitra, also dilate blood vessels and can cause hypotension when used in combination with other vasodilators. Therefore, Medic 5 may be making a serious mistake by assisting the patient with nitro when he may have taken Cialis.
Drug allergies: Many patients report drug Ë™allergies,à“ which may range from minor side effects, such as a queasy stomach, to life-threatening anaphylaxis. The drugs most commonly implicated in true allergic reactions are antibiotics in the penicillin and cephalosporin category, with the percentage of the population allergic to these drugs reported as 1% to 8%.13
Other medications that may cause allergic reactions include sulfonamide (sulfa) antibiotics, aspirin and other non-steroidal anti-inflammatory drugs, and insulin. Treatment protocols for anaphylaxis are the same regardless of whether the reaction is to prescription drugs or other substances.14
It’s important to ask all patients about drug allergies, and responses should be reported to the ED. Drug allergies rarely interfere with the use of prehospital drug therapies. For example, an allergy to sulfa drugs isn’t a contraindication to morphine sulfate. When in doubt, consult with on-line medical control.
Other adverse drug effects: In addition to unintentional overdoses and true allergic reactions, other adverse effects include predictable but undesirable side effects, unusual side effects and secondary side effects (such as injuries from drug-related falls or choking).
Non-medical use: Recreational use of prescription drugs is the second most common category of drug abuse and is growing. In 2005, 15.2 million people over the age of 11 reported illegal recreational use of prescription drugs within the previous 12 months, about 40% fewer than reported marijuana use but several times more than reported use of cocaine, inhalants or hallucinogens.15 A separate survey estimated that 496,000 ED visits in 2004 were related to non-medical use of drugs. Drugs commonly abused include opioid painkillers, such as hydrocodone and oxycodone, and antianxiety drugs, such as alprazolam and diazepam.11
As with suicide attempts, when patients may also be uncooperative, priorities for emergency patient care include ensuring scene safety, maintaining effective oxygenation of the tissues and providing a comprehensive history to hospital staff.
A short list of drugs you should know
Faced with the dizzying complexity of modern drug therapy, where do you start in trying to understand the medications your patients take? Table 1 presents a suggested list of 20 drugs that every responder would benefit from knowing. These drugs were selected for inclusion based on their prevalence and relevanceÆ’prevalence in terms of how they’re prescribed (see also Table 2) and relevance in terms of emergency medical care.”ž(Download a more complete list of the top 50 drugs below.)
See April 2008 JEMS for Table 1.
See April 2008 JEMS for Table 2.
These lists are intended for use by emergency responders only in combination with other assessment tools, most notably questioning of the patient and their family. As noted previously, drugs can be prescribed for any reason, even if they’re approved only for a single use.
Other resources
For responders interested in deepening their knowledge of patient medications, the following suggestions may be helpful:
Consider buying”žEMS pocket guides. These guides are very useful and typically list hundreds of generic and brand name drugs, along with common indications for use. These lists will also help you spell drug names correctly in reports to hospital staff.
Have desk references available at your station. These references enable you to build your knowledge of specific drugs. Although well known, the Physician’s Desk Reference and nursing drug guides provide far more information than you usually need (or want). I recommend guides written for patients and their families because of their relevance and clarity. These include The Pill Book; The Complete Guide to Prescription and Nonprescription Drugs, by H. Winter Griffith and Stephen W. Moore; The PDR Pocket Guide to Prescription Drugs; and Worst Pills, Best Pills, by Sidney Wolfe and colleagues. For a review of reference books and Web sites, see Ë™So many pills, so little clarity,à“ by Mary Duenwald (The”žNew York Times, Feb. 7, 2006).
Utilize the Internet by entering any drug name into a search engine. Sites with comprehensive information include www.MedlinePlus.gov, www.SafeMedication.com, www.Drugs.com and www.DrugDigest.org. Beware of Web sites that are essentially advertising vehicles.
A new day
It looks like another busy shift in your town. Medic 1 is at a nursing home with an 85-year-old patient who has a fever of 101_ and a blood pressure of 90/50. She takes Zithromax. Meanwhile, Medic 2 is on scene at a high school locker room where a 15-year-old boy was found unconscious and barely breathing. He takes Singulair. Medic 3 is at a private home, where a man has fallen down a flight of stairs. He takes Coumadin.
At another residence, Medic 4’s patient denies any medical history but has prescriptions for Lexapro, Dilantin and Percodan. And Medic 5 is on scene with an elderly man who is pale and feels faint. He has a prescription for metoprolol from Dr. Smith and a prescription for Tenormin from Dr. Jones.
Want clues to the clues? Take a look at the chart with the top 50 drugs you should know at”žwww.jems.com/jems. (Download the pdf below)
Review questions
Test your comprehension with this post-article quiz. Answers are provided at the end.
1. Reviewing a patient’s medications during patient assessment is important because it:
a. gives the family a needed distraction
b. can provide clues to underlying diagnoses
c. offers insight to the social status of the patient
d. assists in determining the correct chief complaint
2. Your partner is a recent graduate of a local paramedic program. He confesses to you that he’s weak in recognizing patient medication names and indications. You tell him that one of the best ways to learn patient medications is to:
a. discuss patient medications with his family physician
b. research patient medications thoroughly at the public library
c. wait and learn about patient medications on the job during each run
d. study the medication reference book in the station library
“ž
“ž
3. A family says their 86-year-old father has become increasingly confused and has been falling the past few weeks. During your evaluation, you find that he’s on 14 different medications from four different physicians. You’re concerned because you know that elderly patients are at risk for:
a. increased sensitivity to medications
b. psychiatric emergencies
c. unintentional overdoses
d. both a and c
4. You’re dispatched to a Ë™suicide attempt.à“ While en route, dispatch relays that your patient is a 42-year-old female who may have overdosed on amitriptyline. You and your partner don’t recognize the medication and are unsure of its use. To best prepare for this patient encounter, you:
a. look up the medication in your”žEMS pocket drug guide
b. wait and ask the patient why she’s taking the medication
c. call your”žEMS instructor to get a quick lesson on the medication
d. do nothing and treat the patient’s symptoms as they become apparent
5. In managing the prehospital care of an intentional overdose patient, it’s important to assess the scene thoroughly because:
a. the patient may be able to go directly to a psychiatric rehab facility
b. you may be able to call the patient’s psychiatrist for guidance
c. you have access to information that might be important to the ED physician
d. the police will need the information you uncover
6. En route to a Ë™medical emergency,à“ you’re given the information that your patient is complaining of dizziness and takes metformin. Your patient probably has a past medical history of:
a. aortic aneurysm”ž
b. diabetes”ž
c. deep-vein thrombosis
d. hypertension
7. You’re assessing a 28-year-old female who tells you that she’s on Inderal. Knowing Inderal is used as an antihypertensive agent, you ask about a history of hypertension. She relays she doesn’t have high blood pressure. You:
a. assume she doesn’t know what she’s talking about and document a history of hypertension anyway”ž
b. advise her that her blood pressure is good because her medicine is doing what it’s supposed to
c. recall that drugs can be prescribed for other reasons outside their intended use”ž
d. take the opportunity to educate her about hypertension and Inderal
8. When using the Internet to learn more about patient medications, choose a resource that:
a. provides clear and comprehensive information”ž
b. allows you to interact with others on a blog”ž
c. is linked with a local hospital’s Web site search page
d. is a pharmaceutical advertising site
9. Which of the following medication issues can complicate prehospital assessment and management of patients?
a. Patients’ chief complaints are seldom related to their medications.
b. The non-medical use of prescription medications is on the rise.
c. Recreational drug use is less common than it used to be.
d. Generic formulations aren’t equivalent with their brand-name drugs.
10. You’re dispatched to an Ë™injured person.à“ While en route, dispatch relays that your patient is a 64-year-old female who accidentally cut her finger on broken glass and can’t stop the bleeding. She also has a history of heart disease and is on Coumadin. The excessive bleeding is most likely because:
a. it’s a compensatory response to the blood loss
b. the patient isn’t holding proper pressure on the wound
c. a major artery has been lacerated
d. the medication is an anticoagulant
Acknowledgements:”ž The author thanks Kelli Butenko, Jeffrey Dzieweczynski, William Gallea, Tom Literski, Andrew Michel and Candida Quinn for their advice.
References
- Slone Epidemiology”žCenter. Patterns of Medication Use in the United States 2005, Boston: Boston University; 2006.
- Avorn J. Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs, New York: Knopf; 2004.
- Kaiser Family Foundation. Ë™Total number of retail prescription drugs filled at pharmacies, 2005.à“ www.statehealthfacts.org.
- U.S.Food & Drug Administration. Approved Drug Products with Therapeutic Equivalence Evaluations. 27th edition, Cumulative Supplement 04, Maryland: FDA; 2007.LI>
- Wolfe SM, Sasich LD, Lurie P. Worst Pills, Best Pills, New York: Pocket Books; 2005.
- Hing E, Cherry DK, Woodwell DA. Ë™National Ambulatory Medical Care Survey: 2004 Summary.à“. Advance Data From Vital and Health Statistics 2006;374:28-30.
- Safran D, Neuman O, Schoen C. Ë™Prescription drug coverage and seniors: Findings from a 2003 national survey.à“Health Affairs (web exclusive). http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.152.
- Radley D, Finkelstein S, Stafford R. Ë™Off-label prescribing among office-based physicians.à“. Archives of Internal Medicine 2006;166:1021-1026.
- Budnitz DS, Pollock DA, Weidenbach KN. Ë™National surveillance of emergency department visits for outpatient adverse drug events.à“. JAMA 2006;296:1858-1866.”ž
- U.S.Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/ncipc/osp/data.htm.
- U.S.Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2004: National Estimates of Drug-Related Emergency Department Visits,”žMaryland: SAMHSA; 2006.
- American Academyof Pediatrics Committee on Drugs. Ë™Acetaminophen toxicity in children.à“. Pediatrics 2001;108:1020-1024.
- Arshad SH. Allergy, New York: Elsevier Health Sciences; 2002.
- El-Tobgy E, Rupp T. Ë™Anaphylaxis: Vicious chain reaction.à“. Journal of Emergency Medical Services 2002;27:84-93.
- U.S. Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings,”žMaryland: SAMHSA; 2006.”ž”ž”ž”ž
Kevin Quinn, MA, EMT-P, is a paramedic at St. Peter’s Hospital in Helena, Mont., and is employed full-time as director of payment method development for ACS Government Healthcare Solutions. He has been involved in EMS for 20 years.
