Imagine hearing this radio traffic:
Rescue 5 to Regional Hospital: We have a 53-year-old male in severe chest pain for 10 minutes. He has shortness of breath, he is sweating profusely and the pain is radiating down his left arm. He rates the pain on a scale of 1 to 10 as a 9. Additionally, our monitor is showing he has a STEMI [ST segment elevation myocardial infarction].
Rescue 5, this is Dr. Jones: if the patient does not have any allergies to any medicines, please administer 6 milligrams of morphine and repeat another 2 milligrams as needed until the pain subsides.
Dr. Jones this is Rescue 5: we do not have morphine, we are out of it.
Ok, Rescue 5, this is Dr. Jones: please administer 50 milligrams of fentanyl and repeat another 50 if necessary.
Sorry Dr. Jones, this is Rescue 5: we are out of fentanyl also.
Rescue 5, this is Dr. Jones: do you have Demerol?
Dr. Jones, this is Rescue 5: negative we do not have Demerol and the patient is still complaining of a crushing substernal chest pain.
Rescue 5, this is Dr. Jones: transport immediately to this hospital and hopefully we have pain medications here at the hospital.
No, not these days. EMS providers are experiencing profound shortages of critical and needed drugs. Chief EMS officers find themselves these days begging their local suppliers, begging hospital pharmacies or borrowing from other fire departments until they get a shipment of needed supplies in.
The first warning signs came in 2010 when intravenous cardiac epinephrine and dextrose were suddenly in short supply—and in some cases unavailable for purchase from any manufacturer. Unfortunately, these are two of the most commonly used drugs in EMS. Many chief EMS officers found themselves scrambling to get hold of these two common drugs to get through the crisis.
Now in 2012, the situation has worsened. Shortages of midazolam (Versed), diphenhydramine (Benadryl), morphine, diazepam (Valium), lorazepam (Ativan), epinephrine 1:1000, etomidate, fentanyl, magnesium, sulfate, ondansetron (Zofran) and mannitol are not uncommon.
As indicated by the secretary of the U.S. Department of Health and Human Services in October 2011, while a very small number of drugs in the United States experience a shortage in any given year, the number of drug shortages nearly tripled between 2005 and 2010.
Many people differ on the root of this problem. Some blame government agencies, such the Food and Drug Administration (FDA) or the Drug Enforcement Administration, that regulate drug manufacturers. Some blame drug manufacturers who focus their goals on profits and concentrate on only making drugs that bring them the most profits. Finally, some people blame both the government agencies and the drug manufacturers.
But we can't afford to play the blame game. Whatever the problem is, fire departments are caught in the middle and unable to do the best we can for our patients.
What Is the Fire and EMS Community Doing?
The IAFC and its EMS Section issued a position paper (PDF) citing the problem and its cause. The paper offers what the IAFC believes government agencies and drug manufacturers should do and offers guidance to fire departments and EMS agencies on how to minimize the impact of the drug shortage.
This past March, the Joint Leadership National EMS Leadership Forum met to discuss issues of common interest, including the drug shortage. From those discussions, a subgroup was formed to try to deal with the drug shortage situation and possibly help find solutions.
Letters were sent to Senator Tom Harkin, chair of the Senate Committee on Health, Education, Labor & Pensions, and to Representative Fred Upton, chair of the House Committee on Energy and Commerce (the letters are posted on the EMS Section's webpage). They point out that very little attention has been focused on the impact the drug shortage has had on EMS systems, and they ask that their committees continue to work on drug-shortage legislation to address the unique needs of the fire and EMS community before delays and disruptions in patient care become even more widespread.
What Can You Do?
If you’re the fire chief, you need to keep current on the status of the drug shortage and how it’s affecting the service your department provides, since there are significant liability risks. With more and more information about this issue appearing in the media, you need to be prepared to answer questions from your political leaders and the media about what your department is doing to address the shortage and prevent any adverse occurrences to the citizens. You need to work closely with your EMS staff to ensure they have the funds and other resources necessary to address the shortage and ensure the safety of your personnel and the patients they serve.
If you’re a chief EMS officer, get your medical director in the loop; see if there are any protocols that he or she wishes to modify either because of an existing shortage or to prepare for potential shortages. For example, some fire departments are having laboratories examine expired drugs to verify whether the drugs are still valid. A letter from the lab that they’re still valid and what the expected shelf life is may give your medical director comfort with allowing those drugs to be used until an unexpired shipment of drugs is received.
Chief EMS officers must continually stay on top of this crisis. The FDA has a dedicated drug-shortage website where you can find a lot of information about what drugs are being reported in shortage.
It's not likely we'll see a solution to this crisis in the near future. Unless the government agencies and drug manufacturers make significant changes, this problem will continue unabated. Hopefully a solution will be found soon!
Gary Ludwig is the deputy fire chief of the Memphis (Tenn.) Fire Department. Gary serves as chair of the EMS Section’s board.