No. 04 - 01
Date: April 19, 2004
Re: EMT-B Assisted Delivery of Prescribed Medications
Assisted Patient Administration of Prescribed Medication by EMT-Bs - Nitroglycerin (tablet or spray), Bronchodilator (inhaler), Epinephrine (auto-injector)
To provide Emergency Medical Technician - Basic (EMT-B) responders belonging to Westchester Regional 911 EMS agencies with regional guidelines to assist patient administration of certain pre-prescribed medications; nitroglycerin (tablet or spray), bronchodilator (metered dose inhaler), epinephrine (auto-injector).
The State Emergency Medical Advisory Committee (SEMAC) and State Emergency Medical Services Council (SEMSCO) have established a training curriculum for EMT-Bs that includes the recognition of medical emergencies pertaining to anaphylaxis, chest pain and respiratory distress. As part of the evaluation and treatment for these conditions, EMT-Bs are instructed in the indications, contra-indications, administration and potential side effects of epinephrine (auto-injector), nitroglycerin (tablet or spray), and bronchodilators (metered dose inhalers), when assisting a patient in taking prescribed medications for each of these situations respectfully.
The New York State Department of Health (NYSDOH) Basic Life Support (BLS) Adult and Pediatric Treatment Protocols outlines assisted patient administration of medications in protocols:
§ M-3: Anaphylactic Reactions With Respiratory Distress or Hypoperfusion
In creating this policy, the Westchester Regional Emergency Medical Advisory Committee (REMAC) is providing off-line medical control for assisted delivery of pre-prescribed patient medications by regional EMT-Bs completing patient care in conjunction with these protocols. With any medication administration, ALS must be requested to respond.
CLARIFICATION OF NYS DOH DEFINITIONS:
According to NYS DOH policy No. 99-01 Re: EMT-Basic Assisted Medications:
1. Pre-prescribed medications are those medications that are prescribed for a specific patient prior to an emergency and are present at the scene of the emergency. Experience has shown that "assisted medications" may not be labeled with the patient's name on the container, inhaler or auto-injector carried by the patient. In this circumstance if the patient indicates a desire to take the medication, AND the medication has been identified as being the patient's pre-prescribed medication by a claim or an appearance (is in the patient's pocket or purse, etc), AND the patient exhibits signs/symptoms consistent with the indications for the medication, AND the medication is not contraindicated by protocol or the EMT-B's training, then the EMT-B should assist in delivering the medication. In no case should an EMT-B assist in the delivery of a medication from a container, inhaler, or auto-injector that is not labeled with the name of the medication. Also, medications belonging to other family members or bystanders ARE NOT to be utilized under any circumstances.
2. "Assisting" means delivering a patient's pre-prescribed medication, regardless of who delivers the medication. A certified EMT-B should deliver pre-prescribed patient who exhibits signs/symptoms consistent with the indications for the medication and the medication is not contraindicated by protocol or the EMT-B's training. For cases where a patient indicates a desire to take a medication but it is contraindicated, the medication should not be provided.
EPINEPHRINE (auto-injector, Epi-Pen):
1. The patient has a diagnosed history of anaphylaxis, severe allergic reactions and/or a recent exposure to an allergen or inciting agent,
2. If either cardiac or respiratory status are abnormal,
3. The patient having severe respiratory distress or hypoperfusion has been prescribed an epinephrine auto injector; assist  the patient in administering ONE (1) EPINEPHRINE auto-injector (Epi-Pen).
4. No repeat dosing is allowed. If needed, and a second Epi-pen is available, on-line Medical Control MUST be contacted.
NITROGLYCERIN (tablet or spray)
1. If the patient has a diagnosed history of angina, heart attack or other significant cardiac condition,
2. Chest pain is present and the patient possesses nitroglycerin prescribed by his/her physician,
3. The patient has a systolic blood pressure of 120mm Hg or greater, the EMT-B may assist  the patient in the sublingual administration of ONE (1) tablet or metered dose spray of NITROGLYCERINE.
4. If inadequate relief is achieved, assisted administration may be repeated every five (5) minutes, up to a total of three (3) tablets or sprays, if the patient’s systolic blood pressure remains 120mm Hg or greater.
BRONCHODILATOR (metered dose inhaler)
1. If the patient is exhibiting respiratory distress caused by an exacerbation of previously diagnosed asthma,
2. The patient has a prescribed bronchodilator medication metered dose inhaler (MDI),
3. The MDI is not a steroid based medication, the EMT-B may assist 2 the patient in administering ONE (1) MDI treatment, consisting of TWO (2) puffs of the BRONCHODILATOR.
4. A second, ONE (1) MDI treatment may be repeated in fifteen (15) minutes if inadequate relief is achieved with the initial treatment.
ON-LINE MEDICAL CONTROL
Medical Control MUST be contacted under the following conditions:
ADVANCED EMTs WORKING FOR BLS SERVICES
Advanced EMTs that are working for a BLS Ambulance Agency in a BLS capacity may only assist patient administration of certain pre-prescribed medications; nitroglycerin (tablet or spray), bronchodilator (metered dose inhaler), epinephrine (auto-injector) as per NYSDOH BLS Protocols. Significant protocol differences exist between ALS and BLS administration of these medications. Per NYSDOH, providers may not practice outside the level of care regionally approved for the agency.
Issued and Authorized by:
Dr. Nicholas DeRobertis, MD, FACEP
 There may be scenarios in which a patient experiencing anaphylaxis may not be able to indicate his/her desire to take a pre-prescribed Epi-pen and the EMT-B must make the decision to do so. In cases of an allergic reaction, as opposed to anaphylaxis, the patient should be able to participate in the decision and the delivery of the epinephrine.
 There is no circumstance when it would be proper to deliver either nitroglycerin or a bronchodilator to a patient who cannot indicate their desire to take their pre-prescribed medication. As stated, this procedure prevents an EMT-B from delivering either of these medications to an unconscious or unwilling patient. .