Medical Director Update 2022

Dr. James Winslow, Medical Director, NC Office of EMS

I want to give a brief update on EMS in North Carolina. Right now, there are some exciting things going on in North Carolina, but we also have some challenges. Recently eight systems were awarded grants from the North Carolina Department of Health and Human Services to provide medication-assisted therapy for patients with opioid use disorder. Other EMS systems are also doing exciting work with harm reduction. As we all know, the entire health care system is under significant stress. Many EMS systems have had to deal with hospitals who have placed themselves on diversion. Other EMS systems have also been called upon to perform interfacility transfers at a time when those same EMS systems have limited resources available. While all this is going on, we also must remember that the personnel who have felt the calling to work in emergency services have a huge ability to help people when they are at their most vulnerable and when they need help the most. We cannot forget how important our jobs are.  We are extremely lucky to have the ability to make such a huge difference for people.

The opioid epidemic is not getting better. If anything, it is getting worse and still claiming many lives. EMS is in a unique position to help mitigate the effects of this crisis. North Carolina was the first state in the nation to initiate EMS-based needle exchange combined with harm reduction measures. It has been shown that needle exchange programs are one of the most effective ways to help people with opioid use disorder. Many EMS systems are leaving behind naloxone with patients and using peer support personnel to reach out to many people with opioid use disorder.  

North Carolina has also been leading the way with EMS-initiated medication-assisted therapy for persons with opioid use disorder. Suboxone is an excellent medication to help people with opioid addiction. It is a partial opioid agonist. This means that Suboxone does not completely activate a person’s opioid receptors. Heroine and Fentanyl are full agonists, so they completely activate a person’s opioid receptors. One way to think about this a like a car accelerator. A full agonist like Heroine would completely activate pain receptors, kind of like a person pushing a car accelerator all the way to the floor and revving the engine. A partial agonist like Suboxone only partially activates pain receptors, like pushing a car accelerator down a little bit, so the engine goes just above idle. Suboxone also sticks very tightly to pain receptors and prevents other drugs like Heroin or Fentanyl from attaching to pain receptors. Suboxone stays attached to pain receptors for about 24 hours. Suboxone’s unique properties mean that if a person takes Suboxone, they are very safe from overdose for about 24 hours, and they also don’t have any cravings for that time period. Several counties have had medication-assisted bridge programs in place for the last three years. A bridge program is when an EMS community paramedic visits a patient after an overdose reversal. The medic will offer them Suboxone and referral to an outpatient-based treatment program where they will continue to receive Suboxone as an outpatient. The community paramedic administers the patient’s Suboxone at their home for up to seven days while the EMS agency works at getting the patient plugged into an outpatient program. While the patient is taking Suboxone, they are unlikely to have cravings and are very safe from overdosing. Recently, eight counties in North Carolina were awarded grants to implement new medication-assisted bridge programs. This will bring the total number of EMS systems in North Carolina providing this service to 11.

Hospital diversion has also been a significant issue over the last few years. Some hospitals will declare themselves on EMS diversion when they feel that their Emergency Departments are overwhelmed. EMS systems are not under any obligation to honor hospital diversion status due to emergency department overcrowding. A hospital cannot refuse to see a patient brought to their emergency department. That being said, it’s recommended that EMS systems should proactively work with their hospitals in a collaborative way to help mitigate the effects of hospital overcrowding. Emergency Departments should also not have long delays in taking over care of EMS patients once they arrive at the hospital.  

Many EMS systems are asked to help with interfacility transfers. It is important to remember a few important issues regarding interfacility transfers. EMS crews should never transfer a patient that they believe that is too complex for them to manage. The hospital does not make the decision whether an EMS unit has the capability to care for a patient during an interfacility transfer. If the EMS crew feels uncomfortable with a case, they should contact their supervisor and or medical director. Also, an EMS crew should not give medications and do procedures that are outside their scope of practice. For example, if a patient is receiving Precedex or has a balloon pump placed, a paramedic cannot be primarily responsible for that patient. Precedex is a medication not included in the scope of practice for paramedics in North Carolina. A balloon pump is a procedure/skill that is outside the scope of practice for paramedics in North Carolina. Even if a procedure or medication is within their scope of practice, they should not administer any medication or perform any procedure that they are not trained on. For example, if a patient is on a Propofol drip and a paramedic has not been trained on that drug, then the paramedic should also not assume care of that patient even though Propofol is within the scope of practice for paramedics in North Carolina. 

We live in challenging times. There are not enough EMTs, advanced EMTs, paramedics, or nurses to adequately staff the healthcare system. Everyone is stressed. That makes what you do even more special. As medical professionals who work in the emergency setting, you take care of people who go through the scariest moments of their lives. You do things that no one else can do. Few others can care for someone who thinks they are going to die, save their life, and comfort them and their families at the same time. I can think of no greater calling than that of an emergency medical provider. Thank you. 

Dr. Winslow has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the North Carolina Office of EMS in 2011. This document contains all protocol, procedures and policies for all EMS agencies in North Carolina.

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