Wake County Posts EMS Directive for Saline Shortage

What is your system doing for the saline shortage?

Wake County EMS Directive
Situation: We have a critical shortage of normal saline.

Background: The multi-factorial national drug shortage continues and has now affected normal saline. We now have a very limited supply of normal saline and it is unclear when more may become available.

Assessment: We must immediately take action to limit the administration of normal saline to patients with specific illness or injury.  This change in practice, since prescribed by the Wake EMS System Medical Director, does not increase the liability for responders who are no longer administering IV fluids to patients for whom they historically would have.


1.  It is important to clearly document in ESO which IV therapy you use.

a. If you start a saline lock, please use the procedure “IV Therapy – Saline Lock”

b. If you are starting a 500cc, 1000cc or larger bag of fluid and/or cold fluid, please use the procedure “IV Therapy – Normal Saline or Cold Saline”

2. IV fluids of 500cc, 1000cc or larger may be initiated on patients who are symptomatic from their injury or illness and have a systolic blood pressure of less than 90.  This includes,  but is not limited to, patients with the following conditions:

a. Cardiac arrest

b. Heat emergency with corresponding body temperature >101 F

c. Anaphylaxis

d. Blunt or penetrating trauma

e. Blood glucose reading of “High”.  If a numeric value is present, the patient should not receive IV fluids

f. Inferior MI

g. All burn patients being transported to a burn center regardless of their blood pressure

3. If you are treating a cardiac arrest patient, please follow these guidelines.  Once access has been obtained, attach only a saline lock until the 500cc, 1000cc or larger bag of cold fluid arrives, unless the cardiac arrest is clearly related to hypovolemia (e.g. you are immediately on the scene of a penetrating trauma arrest).  DO NOT administer a bag of non-cold 500cc, 1000cc or larger bag of Normal Saline for most medical arrests.

a. Administer COLD Saline to medical arrests once cold saline arrives on scene. Only use a single bag of 500cc, 1000cc or larger bag of cold saline on cardiac arrest patients, unless:

i. The patient regains ROSC and is transported. In this case,  go ahead and hang a second 500cc, 1000cc or larger bag of cold saline

ii. If the first bag is empty and the resuscitation is going to continue then you may hang another 500cc, 1000cc or larger bag of cold saline

4. We have traditionally treated intoxicated patients at special events with a normal saline bolus.  However, given the shortage, we will not be able to continue this practice.  These patients should not receive fluid bolus unless they meet one of the above criteria listed in bullet #2 to receive IV fluid.

5. Medication drips utilizing 250cc or other prescribed size bags are not affected by this directive.  These bags are for medication administration only and NOT for volume bolus.  Continue to utilize the medication label for proper mixing and administration.

a.   Patients who receive IV drip medication often require IV fluids as well. However, you may attach the medication drip directly to a saline lock.  If you feel the patient would benefit from additional IV fluids of 500cc, 1000cc or larger you may administer IV fluid regardless of whether they meet one of the indication(s) listed in bullet #2.

6.  As always, if you feel a patient has a particular need for IV fluid that is not addressed in this list, you should contact medical control for further guidance.  DO NOT administer IV fluid outside of these guidelines without contacting medical control.

M. Bachman

Is Amiodarone a Wolf in Sheep’s Clothing?

Danny Cline

Somewhere along the way someone in charge of something said, “If Amiodarone works in cardiac arrest, HOT DAMN it’s gotta work for just about everything!” And a few papers came out, and like sheep EMS systems across the country seemingly put this drug into every “ventricular problem” protocol. It has become the answer to everything from stable wide complex tachycardia to VF.

Truth is, the more I read about Amiodarone, the more concerned I become about it being standard first-line for ventricular dysrythmias. I start with some literature that is currently out there. And remember the AHA guidelines state: “There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge.”

SIX studies (Boriani et al ‘96, Gaita et al ‘92, Schutzenberger et al ‘87, Sheinman  et al ‘82, Tijunelis et al ’05) found that the use of Amiodarone in ATRIAL FIBRILLATION with WPW (Wolff-Parkinson-White – often mistaken as VT) resulted in patient deterioration and/or death.

Ever use Amio in a pregnant patient? Did you know there is a risk of fetal hypothyroidism, mental retardation, bradycardia and prematurity? I did not know that…

This is an EKG of a young female that presented to an ED with wide complex tachycardia, later to be determined it was atrial fibrillation with rapid ventricular response. She was stable. She had a history of WPW:

Following administration of Amiodarone:
There were also several cases of patients with prolonged QT interval where Amio had a negative impact.

This is an EKG of an alcoholic patient complaining of severe palpitations, dizziness and was marginally hypotensive. Note the prolonged QT:

Following the Amio bolus:
homer-dohThere are multiple documented cases of this. Pre-existing prolonged QT interval patients given Amio, go into Torsades. In one paper I read of 4 incidents  where Amiodarone caused PQT to digress to Torsades, and many others are mentioned throughout the literature.

Another sphincter-tightening theme that was very clear was when Amio was given for wide complex tachycardia in the presence of hyperkalemia.

Here’s another EKG. (QUESTION: How is a paramedic to know this patients potassium was 9.2?) She was profoundly hyperkalemic. Here is the rhythm she started in (dizziness, weakness, mild dyspnea and fluttering in her chest):

The subsequent strip was not shown in the paper. It didn’t need to be because it was asystole.

One more EKG – this is a gentleman that presented “stable but symptomatic“ with a heart rate of less than 120/min. It was determined later he had an accelerated idioventricular rhythm.  It was diagnosed as a wide complex tachycardia:

(Before Amio)
Amiodarone was administered… the patient went into asystole. He is deceased.

A little more about  Amio for stable VT from two additional studies;  According to Marill (Annals, ‘06) the conversion success rate for stable VT was 29%. Lidocaine has a similar success rate.

Then there’s the Tomlinson paper (Emerg Med J, 2008) that yielded the exact same results: a 29% success rate for conversion.  AND, a caveat – it doesn’t work fast either. Only 15% converted in the first 20 minutes according to his research.

My last and final pitch to examine Amiodarone is to cite the 2006 collective agreement by executive summary in 2010 to demote Amiodarone from a class IIa anti-arrhythmic to a class IIb, and promote procainamide to a Class IIa for stable, monomorphic VT. Yes, you read that correctly.

This was not a peer review group, folks. This was the American College of Cardiology, American Heart Association and the European Society of Cardiology collectively making this decision and releasing a statement (executive summary) that should have grabbed the ears of our discipline:

“Intravenous Amiodarone is not ideal for early conversion of stable monomorphic VT. Intravenous procainamide is more appropriate when early slowing of the VT rate nd termination, of monomorphic VT are desired. Amiodarone is reasonable for patients with sustained monomorphic  VT that is unstable, refractory to conversion with countershock, or recurrent despite procainamide of other agents.” –2006 Guidelines for Management of Patients With Ventricular Arrhythmias and Prevention of Cardiac Death – Executive Summary, Circulation, Sept. 5, 2006

So here’s the summation:

Amiodarone is portrayed through the literature and by many ED physician accounts to be dangerous in the following cases:
-Afib with WPW
-Long QT
-Accelerated Idioventricular Rhythm

In 2000 we were told Amiodarone was safe and a limitless wonder for a multitude of dysrhythmias. Now we know it hasn’t proved itself so praiseworthy. EMS systems using Amiodarone should take a serious look at this medication and the literature for and against it, keeping in mind other options for first-line treatment of dysrhythmias such as procainamide. But then again, I am “just” a paramedic.
“WPW? Ya don’t say!”


Faulk Signs, Rutherford to Resign

I was in the process of writing a post about Faulk signing his 6 year 29 mill a year contract.

Then, the bonus package of Cane’s drama unfolded and my revelation that Canes fans and Sabres fans have a few things in common.

News broke about Rutherford likely giving up his duties as GM. Never worry Canes fans… I’m sure the Hurricanes will release something to negate the signing of Faulk and Rutherford’s packing his desk in boxes being any sort of correlation. Welcome to the world of fruitcake hockey management, Cane’s fans. Whatever you may say about Sabres fans, you can’t say we don’t know how that feels. The hope to harbor is that your ownership group figured it out far quicker than the Sabres’ owner did. Say the name “Darcy” in Buffalo and you have to duck…unless you preface it with an “F” bomb ending in ‘ing.


Darcy! Meet me at the bar again! Lets have a few more shots! I just read from the scout report we have this JT Compher kid. We’ll throw in McBain too.” (Laughs hysterically)

Digressing… Back to Faulk

I remember hearing about Faulk when he was in the NCAA. He was opined as an exceptional skater and one with incredible zone IQ (no surprise to Hurricanes fans) – and that he gains possession down low using both brain and brawn. He’s like a quarterback when he’s breaking out of his own zone – he finds outlets. Few would question his chances at being top 2 defenseman. Friends of mine that saw him play for Duluth & the World Juniors agree.

Justin Faulk signed a contract that in the not too distant future was typically signed by a player that earned it. But then, so was the signing of Tyler Myers in Buffalo. We often see this with forwards but not defenseman. Justin should do himself a solid and have a beer with Tyler Myers to see how difficult that actually is to do.

Back to the correlation of Faulk signing and Rutherford resigning (if any)…

GM’s are getting more risky with these big contracts with young kids. They take an even bigger risk at signing a young defenseman. Whoever was the mastermind at getting this signing done, the Hurricanes got this one right in my opinion. But its not a good time to be wrong considering the culture (or lack thereof) of the team right now. It’s one thing to have problems scattered among certain positions on the ice, quite another to have a destination everyone in the front office agrees with.

The Hurricanes seem to be struggling to find an identity. Are they a veteran team that wants to fight for 8th place? (Right now they’re holding a commanding lead in… well… seventh). Are they rebuilding? What’s with the free agents? Hurricanes fans have some legitimate questions and after hearing both of these stories today I’m wondering if the brass in Carolina is split about what the future should look like.

On the bright side, Canes fans, Darcy Regier is for hire.

Welcome to the Blue and Gold Grief Support Group

My name is Dan, and I’m a Sabres fan.

Tailgating during the worst time in Sabres history became a lot like that yesterday in the parking lot of the PNC. Whenever the Sabres come to Raleigh, its a similar scene: About a dozen or more men and women standing around a grill under a blue and gold tent in Sabres attire, listening to Tragically Hip, drinking Molson and Labatt beers, and inhaling the peppery smell of Chiavettas chicken wafting into the air. There’s always somebody you don’t know, and an informal introduction opens with, “Where are you from?” Inevitably the conversation transfers into a dialect about the region or an anecdote related to it. “Clarence, eh? I love the fall festival there! It’s awesome!”

But there was something different about this year. The feel was much more somber; near morbid. In the past when Sabres fans walked past the tent there was howling and chanting, “LETS GO BUFFALOOOOO!!!” They would respond with a fist in the air and a long, drunken barbaric yawp.

Yesterday passersby just put their heads down as if they were walking the dirt path to Golgotha to witness some sort of slow, painful execution. After avidly following this team through this rebuild, it’s as if we all had the daunting premonition that was going to be exactly what this game would feel like. We knew we would have to endure the shrill of ‘Canes fans and the cat of nine tails in the form of insults while the last nail is pounded deep in the wood… then we finally watch our beloved Sabres die slowly and painfully in the last period. We as Sabres fans, mocked and humiliated watch as our team hangs on the cross until the final horn sounds.

Then, it is finished.

If this rebuild can be compared to the grieving process, it is woefully obvious Sabres fans are caught somewhere between depression and acceptance. But I realized a few import things while I was watching ‘Canes fans celebrate another victory. I asked myself why I Miller Sadtook time off of work to do this, and why I spent so much time and energy knowing the outcome would likely not favor us.

You see, there are some things you won’t take away from Sabres fans. They are the intangibles that brought several Buffalonians down to Raleigh – some driving through the night because the March blizzard landed planes – that wanted to see their last place team and in so doing, find some brotherhood and help make it a bit easier on us fans living here to help carry the cross into the arena. Even though there is pain, it’s shared pain.

Meeting a Western New Yorker wearing a Sabres jersey automatically made me feel like I wasn’t alone. We’re still here. Still rooting. And without any words exchanged  there is an instant human connection… one that makes the beer taste a little better, the grill feel warmer and the fulfillment and recognition that it’s ok to be a Sabres fan.

no matterWe have all also gained a collective flair of optimism, which has made acceptance a possibility for all of us. Looking at the pipeline of talent and draft picks we possess and the leadership of Murray, there is hope that there will be a resurrection. We all still believe deep inside that our blood, sweat, money and tears will someday be spilling over that silver chalice in the form of champagne.

I can just hear the voice of Brian Engblom while the Sabres hoist Lord Stanley in its scintillating beauty around the rink, “The fans here in Buffalo are absolutely beside themselves in emotion. The Cup is finally theirs, and boy do they deserve it!”


It’s Time to Dethrone the King Airway

Danny Cline

One of the disadvantages of practicing in my “evidence based system” (Wake County NC) is the variables left out of research that are held hostage in decisions driving our current practice. When the King airway was discovered on YouTube it took our system by storm. And I was skeptical for good reason. Using research to back-up ones argument becomes rather cumbersome when every argument I can conjure against using the King airway in cardiac arrest there is at least one counter argument supporting its use.

And then there’s the literature…oh God, the literature. I’ve read it, I’ve studied the methodologies, and with every paper I have scrubbed I found myself starting right where I left off: unable to posit a stance for or against it. One photo that the research is incapable of developing is an analysis of individual paramedics that have high intubation success rates. This leaves our practice at the mercy of the weakest link.

For all the great and wonderful things the King supposedly does, I have yet to personally witness a success story where the King was utilized to secure an airway. That’s right – every arrest I have seen where a King was placed had a negative outcome. That’s despite proper insertion and multiple care providers. THAT IS NOT SAY no one with a King survives, I’m sure the system analysts will prove me wrong on that.

For me and some other medics I have spoken to it’s the same story in many cardiac arrests: aggressive CPR is commenced, a King is dropped and ALS is rendered. In most cases the patient starts improving. That is, until vomit, blood and whatever other bodily fluids start to creep into the airway and past the seal. Inevitability the SpO2 dips and the ETCO2 rockets upward. Now as a clinician you’re at an impasse. Intubation will be far more difficult than it was to begin with, so you’re left with the next option. How many of you have gone through two Kings on a code?Without doing a literary review and combining all of the numbers for and against, I need to make it clear again that I am speaking pragmatically from my own experience. What I will do is give the reasons our system has chosen to go to King as the primary airway.

Probably the number one reason the King airway was crowned is to keep CPR uninterrupted. Knowing the focus in our system on uninterrupted compressions, particularly at the time the King was introduced into EMS practice, makes me fairly confident that this was the driving force.

A lack of paramedic experience was another justification. Dove-tailing this with low frequency of intubation makes the King a “better choice”.

I can’t speak for the system’s true intubation attempt/success rate, (I no longer have access to that, much to the chagrin of some folks) but I would only have to assume they are sub-optimal. As a side note, what I would really like to see is the number of successful first attempt ET intubations in the ED where compressions are stopped for a life-time – literally.

I have grown to gather a good amount of experience with both endotracheal intubation and using the King airway (23 by 4, respectively). In the cases I have witnessed personally, the King often fails the first time around, sometimes the second time around.

Endotracheal intubation seems to work every time so long as the technique is good and (obviously) if it’s in the right place. Ventilating through CPR is far easier, the airway stays clean and clear, ETCO2/SpO2 plateau and sustain likeable numbers. Even if the patient outcome would be the same, the airway is FAR more manageable and less maintenance.

The loss of emphasis on ET intubation is worrisome to me. I am fearful that we are taking a good airway and throwing the baby out with the bathwater. Intubation can be an excellent airway device without compromising patient outcome. There are things we can do within the system to try to bring back what (is in my opinion) the best airway in emergency medicine.

Far be it from me to be void of solutions. Some brain junk splattered on canvas…

Not everyone can intubate during CPR. I get that. But we can still keep it in the algorithm with a caveat – you only get two shots at it. The first attempt is while CPR is in progress. Take a look and see if you can hit the vocal chords. The second attempt (if the first was unsuccessful) is during the first pulse/rhythm check. You get a narrow window of time during the pulse check and rhythm check to drop the tube. Since we now have the clever idea of a Code Commander, that paramedic (donned with a Cap’n Crunch hat of course) can have a stopwatch or time device, or use the metronome for so many seconds for the tube, then right back on the chest. The Code Commander will have to have a “too bad, so sad” demeanor when the bell rings. With all the equipment prepared, the intubation MUST occur within that period of time. A King airway will be on standby in the event intubation can’t be done within the given time frame.

There is always the option of keeping the King in place and intubating. I am not a fan of this option because it negates the idea that ET intubation should be the primary airway in the first place.

As unorthodox as it may seem, why don’t we have one intubation head per station or per truck, and as part of a medics morning inspection they have to intubate the manikin once every shift? This will develop muscle memory in the hand, wrist and fore-arm, help commit the steps to memory and obviously help with the practice of technique and confidence through repetition.

Finally, perhaps we should start looking at more individual metrics for intubation success rates. The system can dispense whatever action they feel necessary for individuals with frequent missed attempts.

Obviously these off-the-cuff ideas need tweaking but if any of them inspire change I believe it’s within our ability and best interest to step out of our comfort zone and allow the King to return to a back-up airway. Having said that we also need to can the prehistoric idea of “intubate at all costs!”.

We have all the tools to making this a successful venture system-wide if there is buy-in. Together we can put the ET tube back on the throne and stop treating it like a court jester.

Why I’m Not Surprised LaFontaine is Gone

Danny Cline

I’ll keep this short and simple… I am unphased by LaFontaine’s departure and this sentiment was shared by me immediately after Tim Murray was hired.


Even though Pat hired Tim, I knew this was going to be a relationship that wouldn’t walk off into the sunset holding hands. Though I doubt Murray is the sole reason (and God knows the rumors are all over the place right now) I am willing to bet Murray’s dealing with Miller and Ott had something to do with it. I also would not be surprised if there was a disagreement about the re-signing of Nolan.

Another reason I’m not surprised – LaFontaine did this same thing to the NY Islanders. He is a man of his opinions and after 30 days he was off the Island, packing his bags in frustration.

Sabres fans can look at this in two different ways. One way would be to say, “Yup. Here we go again! This is Buffalo’s luck! This is our dysfunction! here we go again.”

The other would just be to understand that this is really not a huge surprise and it’s all part of growing pains. It sucks, no doubt. But better this happens in the early stages of the rebuild them right smack dab in the middle of it. I’m holding out hope that this will just be a passing misadventure on LaFontaine’s part, and the Sabres will be fine.