THE EXPANDED USE OF MEDICATIONS(and who it affects)

by Don Hudson, D.O., FACEP/ACOEP

Remote Sites

Anchorage ER’sPatients

The expanded use of medications by the Remote Site medical staff

These rules will be pertinent only to the medical staff supervised and trained by Dr Hudson and Dr Dow

When in doubt as to what you should do call Dr Hudson or Dr Dow.

The calls should be organized into Emergent, Urgent and Routine. These will be further defined later

Medication Use

Because of the weather and other factors beyond all of our control you have medications on site that you would not normally use. These are to be used at the discretion of Dr Dow &/or Dr Hudson only.

The next few slides explain about the various medications you have on site

Prescription Medication Guidelines This document is to be used as a guide in the use of

common prescription medications. This is a living document and subject to revision at the discretion of the Medical sponsors.

Antibiotics: Antibiotics are only to be utilized at the direction of the

physician for ill or septic patients. Any employee who receives antibiotics must be re-evaluated at least with-in 24 hours of the first contact. Guidelines are to be followed with common sense! All questions or concerns are to be directed to the medical sponsors.

The Medical Director (s) or their designee must be notified before starting any antibiotics. All patients who receive antibiotics will be sent off site.

Distribution of meds

You have PO and IV meds on site. The IV meds will given only at the

discretion of the physician. The patients are assumed to be

very sick, i.e. abscess, septic, MRSA, suspected perforated bowel, open fractures, etc. These are patients who will be transferred to a higher level of medical care.

Antibiotics

AMOXICILLIN Form: 500 mg capsules Class: Semi-Synthetic form of Ampicillin (Penicillin group) Dosing: 500 mg (3) three times daily for (7) seven to (10) days Uses: Upper Respiratory infections, severe dental infections,

sinus infections, Otitis Media. AZITHROMYCIN (Zithromax) Form: 250 mg tablets Class: Macrolide Dosing: 500 mg on day one followed by 250 mg daily on days 2

through 5. This drug stays active in the system for 10 days. Uses: Respiratory infections not responding to conservative

treatment (OTC meds), Otitis, Oral infections.

Antibiotics

CEFAZOLIN (Ancef)

Form: 1 Gram vial Class: Cephalosporin Dosing: 1 Gram IV or IM every 6-8 hours Uses: Trauma, complicated skin infections ANY PERSON RECEIVING ANY IM OR IV INJECTION MUST

HAVE A MEDICAL SPONSOR CONSULTATION IN ANTICIPATORY EVACUATION.

CEFTRIAXONE (Rocephin) Form: 1 Gram vial Class: Cephalosporin Dosing: 1 Gram IM or IV every 24 hours. Uses: Severe infections ANY PERSON RECEIVING AN IM OR IV INJECTION MUST

HAVE A MEDICAL SPONSOR CONSULTATION AND CONSIDERATION OF AN ANTICIPATORY EVACUATION

Antibiotics

CEPHALEXIN (Keflex) Form: 250 or 500 mg capsules Class: Cephalosporin (first generation) Dosing: 500 mg (4) four times daily. Length of course

varies by use. Uses: Uncomplicated cellulitis, respiratory infections,

urinary tract infections, skin and oral infections. CIPROFLOXIN (Cipro) Form: 500 mg tablets Class: Quinalones Dosing: 500 mg (2) two times daily Uses: Urinary tract infections, respiratory infections,

cellulitis of the feet, nail punctures through boots into the feet, and gastrointestinal infections.

Cautions/Contraindications: DO NOT USE IN PREGNANT PATIENTS

Antibiotics

GENTAMYCIN OPHTHALMIC SOLUTION (Gentak eye drops)

Form: 5-10 ml bottle Class: Aminoglycoside Dosing: 2 drops in the affected eye every (4) four

hours, while the patient is awake, for the first (2) two days then (4) four times daily for the next (4) four days.

Uses: Simple conjunctivitis. PENICILLIN (Pen VK) Form: 500 mg tablets Class: Penicillin Dosing: 500 mg (4) four times daily Uses: Exudative pharyngitis (strep throat), oral

infections, rarely used for respiratory infections.

Antibiotics

SILVER SULFADIAZINE (Silvadene) Form: Cream Class: Sulfa Dosing: Varies by use, usually refresh with each dressing

change Uses: First and second degree burns, wound care

treatments, rarely open blisters from frostbite injuries. TRIMETHAPRIM/SULFAMEFOXAZOLE (Bactrim,

Septra) Form: DS tablets Class: Sulfa Dosing: (1) one tablet (2) two times daily Uses: Uncomplicated urinary tract infections. Simple boils,

cellulitis, respiratory infections, MRSA Cautions/Contraindications: It will increase sun sensitivity,

DO NOT USE WITH PREGNANT PATIENTS

Anti-Emetics

DROPERIDOL (Inapsine) Form: 5 mg/ 2 ml vial Class: Phenothiazine Dosing: Varies by use. IV administration is in 0.625 mg

increments (0.25 cc). IM administration is in 2.5 to 5.0 mg doses

Uses: Vomiting, intractable nausea. May use for psychiatric crisis. Always administer Diphenhydramine (Benadryl) with the Doperidol to prevent dystonia.

Cautions/Contraindications: The drug will cause sedation; it may cause dystonia which can be counteracted with Diphenhydramine (Benadryl)

PROMETHAZINE (Phenergan) Form: 25 or 50 mg suppository Class: Phenothiazines Dosing: 25 to 50 mg rectally every (6) six to (8) eight hours

for nausea and/or vomiting Uses: Persistent nausea or vomiting because of pregnancy or

infection Cautions/Contraindications: It may cause sedation and

infrequently may cause dystonia

Pain Medicines

HYDROCODONE/APAP (Tylox, Vicodin) Form: 5 mg Hydrocodxone + 500 mg Tylenol tablets Class: Narcotic pain medicine Dosing: (1-2) one to two tablets every (4) four to (6) six

hours for relief of pain Uses: Moderate pain not relieved with Tylenol or anti-

inflammatory medications. Patient will be transported after use of the medication.

Caution/Contraindication: Sedating LIDOCAINE VISCOUS (Xylocaine) Form: Viscous 4% solution Class: Topical Local Anesthetic Dosing: Varies with use. May mix with (20) twenty ml of

Maalox for relief of gastritis, may use as a topical pain controller on a mucous membrane not to exceed (6) six times daily, oral use not to exceed (2) two doses.

Cautions/Contraindications: Lidocaine toxicity is possible through the mucous membranes, do not provide your patient with more than (20) twenty cc of the solution

Pain medicines

METHOCARBAMOL (Robaxin) Form: 750 mg tablets Class: Muscle Relaxant Dosing: (1) one tablet (3) three times daily for up to (5)

five days Uses: Mild to moderate muscle spasm Cautions: Mildly sedation PHENAZOPYRIDINE (Pyridium) Form: 200 mg tablets Class: Pain relievers for urinary tract Uses: for relief of urinary tract pain and discomfort Cautions/Contraindications: The medicine will turn all

secretions dark yellow or orange. WARN THE PATIENT! It may stain skin or clothing on contact. DO NOT USE IN PREGNANT PATIENTS.

Pain Medicines

TETRACAINE EYE DROPS Form: 15 cc bottle Class: Topical anesthetic Dosing: (1) one or (2) drops in the effected eye

(1) one time only. Uses: Facilitation of eye exam. Cautions/Contraindications: Do not use more

than once or at maximum twice during an exam. DO NOT SEND HOME WITH THE PATIENT BECAUSE IT CAN CAUSE CORNEAL ULCERS WITH FREQUENT USE.

Steroids PREDNISONE Form: 20 mg tablets Class: Steroids Dosing: Varies depending on use. Uses: Respiratory illness (asthma, allergy) and

anti-inflammatory response. Call the medical sponsor for dosing. You may always give (40) forty to (60) sixty mg dose if contact not possible.

Cautions/Contraindications: Patients requiring steroids should be considered for evacuation.

When do you call for advice &who do you call

Dr Dow and I expect you to use common sense about your calls.

Before you call you should gather enough information and be prepared to answer a number of questions.

Make sure you have AMPLE information, allergies, medications, past medical history, last meal, any pertinent events occurring before coming to see you.

Be prepared for answering the following:

Chief complaint History of chief complaint, when,

where, has it ever happened before, what makes it better or worse.

What have you done including a full set of vital signs

What is your impression of the problem

What do you want, transport, medications, etc. that we can help you with.

Definitions of urgency of calls Emergent- These patients obviously need to

go off site for further care. These are the patients normally sent to the ER

These include patients with open Fx, chest pains, abnormal EKG, shortness of breath with low sats., unstable vital signs, altered mental status, seizures, unconsciousness, active bleeders difficult to control with pressure and amputations.

This also includes other disease process that need to get off site.

Emergent Calls

These calls are usually directly to the ER

These are patients who are being transferred to the ER

You are asking for an accepting physician before you sent them in

You may ask for directions; “is there any thing else you want done before they get to you?”

Urgent Calls These are more difficult to define. These

are the sick patients but with stable vital signs who have in your opinion the potential of getting sicker with out some intervention.

The may include dehydration, continuing diarrhea, alcohol withdrawal, Urinary tract infections (+UA test strip), strep throat (+strep screen)

Other sick patients as assessed by you

Urgent Calls

These are calls that need to be directed to Dr Dow or Dr Hudson

Call them several ways by cell, home & the ER if Dr Dow is working in the ER.

The universal # is 907-343-0333 to reach the on-call doc.

The COMMON Phone # for the ON-CALL DOC

343-0333

Phone numbers

Dr Hudson Hm 1-907-337-7990 Cell 1-907-748-7952 Fax 1907-333-3262

e-mail donaldhudson@gci.net Dr. Jennifer Dow

Hm 1-907-783-0186 Cell 1-907-227-2375

e-mail jenndow@mac.com

Routine Calls These are the patients who would wait

until the next office appointment at their doctors office.

They need a trial of OTC medications They have normal vital signs and

essentially a normal examination These patients, in your opinion, will not

get noticeably sicker in the next 24-48 hours

These patients are ones you call about care Mon.-Fri. 9 am to 12noon

Calls

It is a known fact that patients will sometimes get sicker when you least expect it. Any patient you consider routine you should contact in the next 24 hours as well as advising them to return to the clinic IF anything seems worsening

Re-evaluation may cause you to re-consider their status. Respond accordingly.

All patients who are transferred urgently I want a faxed or e-mailed copy or the patient encounter as soon as reasonably possible.

Send this to 1-907-333-3262 See the next page for responsible

actions for sick, deceased, or transferred patients.

Medics Responsibilities

MedicResponsibilities

Calls Follow up with patient Good records

Emergent Urgent Routine

Call the ER

Medivac or transfer

Call Dr Dow or Dr Hudson Call Mon –Fri 9 am -12 am

E-mail copy or fax a copy of the Report to Dr Dow & Dr Hudson

After contact

E-mail copy or fax of note to bothDr Hudson & Dr Dow after

transfer

Fax copy of patient contactsTo Dr Hudson weekly

Why do all of this?

Dr Dow & I are ultimately responsible for you actions and the effect they may have on the patient.

We want to be sure you get enough information to do your job and at the same time assure the patient is getting the best care we can collectively can offer.

When in doubt

Treat every patient as if they were a member of your family.

Always consider several options concerning the patients complaints

Always be a patient advocate and believe their complaints. The complaint may sometimes really be about something else.

Listen carefully

If still in doubt

That is why you have medical back up.

Call us.