If Her Syringe Didn’t Killer Her, Mine May Have

Protocols were the topic of last week’s EMS Office HoursJim Hoffman, Josh Knapp, Dave Aber, Tim Noonan & I discussed how the definition of “consider” and “up to” is different for different people.  I recall a former US president having similar issues.  Like many podcasts, I was reminded of a call I was on.

The text said “21 YOF overdose” on the CAD, after the infamous 9-Echo-1 EMD code for a cardiac arrest.  We walked past fast food wrappers and trash into a crack house, and  down rickety steps into  basement. While the firefighters were doing excellent CPR on the young girl, a number of luckier crack heads were busy explaining to a police officer that they did not see anything or know what happened.  Small empty zip-lock bags were next to her, and one of the firfighters moved a syringe safely away from the action area.  Such is life in the small city on the fringe of a large city where I once worked.

My partner easily intubated her without any pause in compressions, and I placed an IO in her leg.  Her underlying rhythm was a narrow complex PEA, and her end tidal was 40 mmHG with compressions.  Her underlying rate appeared to increase with the compressions, but no pulse was detected and her end-tidal dropped after a pause.  I reluctantly reached into our drug bag.

I did not want to give her epinephrine.  Iwould like to have waited another minute or two to see if our effective CPR and oxygenation would restore her heart beat without having to inject my poison.

We used to think that the time to drug administration was important, and it was one of my service’s performance metrics.  Our medical director at that service also made clear that Narcan should come after epi in suspected opiate-overdose arrests, so even that was not an option. There was nothing to “consider” or “give up to.”

So I gave it.  She went into a perfusing SVT at 180 and her blood pressure was 200/120.  From the time we moved her up the rickety steps to the ambulance, her heart rate and blood pressure came down.  We hung cold saline in the ambulance, and she kept a pulse and blood pressure during transport.  I never learned what her outcome was.

I understand epinephrine is effective at getting a pulse back for patients, and that its side effects may prevent their long-term recovery.  Rogue Medic knows much more about than I do about how harmful epinephrine is, but other people who know more about this than me insist that it should still be given. Any QI officer would say we did a great job, and it would not be our fault if she did not revover.

I just want a little room for judgement.  Rigth now we must give 1 mg of it every 3-5 minutes to any pulseless patient, no matter what their rhythm is, no matter how effective their circulation is with CPR (based mostly on their end-tidal reading), or what the likely cause of their arrest was.  Not giving it not a consideration.  If the patient’s numbers appear to be getting better with the only proven interventions – CPR and defibrillation – isn’t it reasonable to have the option of waiting a little longer to use an unproven treatment?

The answer lies somewhere between cowboy and cookbook medicine.  Go listen to the podcast, join the conversation, and help figure out where that is.  Our patients’ lives depend on it.



  1. These are tough choices that should be left to the physicians. You know, the scientists with 10 years of education. If every paramedic had the chance to do what they want, how could we ever study and learn what works with all the crazy “paramedic variables”. As a paramedic for 35 years I’ve seen hundreds of true saves (neurolologically intact) in our system where epinephrine was administered. It’s far from a poison. Narcan isn’t that important in most narcotic overdose induced cardiac arrest because it’s the respiratory depression that leads to cardiac arrest. You are ventilating the patient so you have, in effect, fixed the cause of cardiac arrest. Wait for the studies that are being done on this very topic. But follow the standard or you are corrupting the data. Finally, learn to understand that you can’t save everyone and you will have a long, healthy, successful career.

    • emspatientperspective says:

      Thanks for the comment, Peter. I grew up and started working not far from you in Buffalo.

      As far as “paramedic variables,” we already have those. My protocol book in Delaware looks much different from New York’s. I have much more room for judgement here and very few things I need to ask permissino for. When I do, there’s even more variation in what physicans may order. We’d like to believe that care is delivered as consistently as hamburgers at McDonald’s taste, but that is not the case.

      As far as epinephrine, I’ll refer you to Rogue Medic’s blog. He knows much more about this than I do. While far from definitive, increased ROSC but lower survival was found in the epi group compared to control in a large Japanese study. It appears that some patients are harmed by it, we just don’t know which ones.

      I do understand that not everyone will be saved, especially people who abuse drugs. I just want a little more room for judgement to avoid inflicting harm on people.


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