Author: David Eng, MD
Assistant Medical Director, Emergency Medical Services
Attending Physician, Department of Emergency Medicine
Maimonides Medical Center
For reference here is a link to all of the NYC REMAC protocols as updated in 2019: https://www.nycremsco.org/wp-content/uploads/2017/10/04-ALS_Protocols-January-2019-vALS01012019B.pdf
Hey there, OLMC pros! Short one for review this week – Protocol 531, Severe Nausea/Vomiting.
Note that, compared to the previous protocols we’ve gone over, this one is entirely Standing Orders, meaning that paramedics can do all of these things, starting with fluid administration and vitals and including the administration of Ondansetron, without physician input. In other words, there are no Medical Control Options for paramedics to call in and request. So why do we care?
Well, first off, did you know that paramedics can give Ondansetron without physician approval? A whole whopping 8mg of it! Any chance you’ve given even more to a patient in the ED without realizing they’ve already got some in their system? Probably!
Now knowing that, take a look at the wording for Step 5, discussing the Standing Order for Ondansetron. If we’re really nitpicking and taking the phrasing as literally as possible (which we should be), what it says is that paramedics can give up to two weight-based doses, each up to 4mg, for a total of up to 8mg maximum. Sounds good so far. But what if you have someone that weighs 30kg, such that each weight-based dose is 3mg, so that after the two doses they’ve received 6mg but are still vomiting? Well, this might be an instance where EMS may call to request a Discretionary Order to give those last 2mg (totaling the 8mg maximum). Should you authorize it? Maybe, maybe not; use your discretion! Is this a young, healthy person with a particularly bad gastroenteritis, or could there be something more at play? Is an extra squirt of Zofran more likely to help or hurt? What information could help you decide?
Those questions speak to the broader point addressed in Step 4 – what other nefarious processes could be making someone vomit this much? Is the patient at risk for an atypical ACS presentation? Hopefully the crew checked an EKG, but if they didn’t prior to calling you, it may be worth politely asking for a 12-lead. Does the patient have diabetes, and this is all coming from DKA? Did the crew tell you the fingerstick? Maybe the right choice is to aggressively hydrate while transporting to the ED.
Once again, this is medicine that you all know, and if you’re dealing with this patient in the ED, you’d all know how to proceed with management. The trick is learning how your thought processes and actions interface with those of our prehospital providers. Once you realize that many patients’ presentation and treatment actually begin in the back of an ambulance and not just when they cross our sliding doors, you can begin to see how comprehensive emergency care here in the city really is.