Who took the sugar?

By James Augustine, MD, FACEP; and Raymond L. Fowler, MD, FACEP, FAEMS

For more than 10 years, EMS leaders have struggled with the ongoing challenge of obtaining basic medications in a form that EMS personnel can use safely. This week, there are about 100 products that are currently unavailable, across all types of medicines used in emergency care.

There have been many efforts to notify federal officials about the impact of EMS drug shortages, and the corresponding increase in the prices of medications that are available.

The last few months have evolved into a crisis in the availability of the medications that are a staple in the EMS drug box. Here is what we know:

• There is essentially no supply of dextrose 50% prefilled syringes. Both manufacturers have had this item on backorder or very limited allocation for over 4 months. The reported date to begin refilling the manufacturing pipeline is February 2023. There may be small quantities in distributor warehouses in the U.S.
• There is essentially no supply of dextrose 10% IV fluids. These have been on manufacturer allocation for over a year. All smaller volume bags (500 mL or 250 mL, regardless of product) have been very limited. When D50 was used as the primary method to administer rescue doses of sugar, there was a historical low volume use of D10 solutions. So, at this time, dextrose 10% solutions have very limited production, and manufacturers indicate no capacity to increase.
• There is now very limited production and shipment of dextrose 5% solutions. This is a solution that has always been used more frequently in hospitals, but has not been used in EMS for years. Once again, manufacturer production is limited, and the majority of the product is shipped to hospitals, so EMS has minimal access.
• Glucagon for intramuscular injection is on backorder. IM glucagon was historically used in EMS for a very short rescue for hypoglycemic patients. But it has been very expensive, clinically less useful, and more difficult to administer in most patients. Major brands have not shipped in 6 months, and remains on manufacturer backorder. Many EMS agencies no longer have this medication in the protocols.

The FDA is aware of the shortages, and is aware of the deeper concerns of EMS about supplies of important rescue medication. They are also aware that the original shortage of D50 was compounded with the protocol changes that made it necessary to introduce D10 in the EMS environment. It is unlikely that there will be manufacturing capacity to support any of the dextrose products for a while. And if the products are being manufactured in a site prone to tropical weather, there is always the potential that shortage could worsen further, as occurred in 2017.

If there is no dextrose or glucagon, what are EMS agencies doing?

EMS agencies can develop programs that can address these shortages, using a six-part process:

1. Manage your protocols. Establish a system that allows several medicines in the protocol for common problems that paramedics encounter (e.g., pain management, low blood sugar, cardiac arrest, heart irregularities, vomiting and seizures). In this case of dextrose shortage, the protocol for a hypoglycemic patient may need to allow the use of D50, D10, D5W, D5 and quarter normal saline, or D5 and half normal saline; and the protocol must specify the amount of fluid that will be required to get to a 12.5 to 25 gram dose of dextrose. Protocols may need to also add the use or oral glucose as soon as the patient can safely take the medicine by mouth. This will ensure that the patient is adequately treated with sugar. Paramedics will need to be aware that giving a 500 cc bolus of D5 solution takes quite a bit of time, and will have to be done without pressure infusing to the point that the IV line ruptures the vein.
2. Put drug boxes in service that are flexible. This is a painful recommendation. Many EMS systems have built very well constructed drug boxes, with a fixed locations for medicines that the paramedic can find even in the dark. At this time, the efficient little box is often now a sack, that has the available medicines in any location, that have to be searched and triple-checked to make sure the right medicine is chosen to be administered. Replacing a box of D50 with an IV bag with 500 cc of D5W requires much more flexibility.
3. Build partnerships. Collaborate with hospital systems, fellow EMS providers and regional distributors who might have supplies that allow as many EMS drug boxes as possible to be filled with products that the paramedics can use. This practice may also allow EMS providers to first use medications that are near expiration dates.
4. Perform active stock management. Work with your logistics manager to give the management team timely updates, and work with other agencies in the emergency system to expand sources.
5. Provide ongoing just-in-time training for the paramedics. This process gives confidence to the paramedics and EMTs that must use products they have not had experience with, and ensures the process is friendly to them.
6. Support the quality management program. This system of evaluating proper and timely medication usage will point to areas that need support from the management team in education, packaging and positive reinforcement.

This is a frustrating problem for patients, paramedics and EMS leaders, and a potentially dangerous one for the patients that we serve. The ongoing challenge of having basic medications in an EMS friendly and consistent form should have been met by medication producers before now. Most of these products have been on the market for 50 years or more. There are a small number of established (and low cost) medications that serve many patients that need emergency treatment. It is time for the federal government to take definitive action to ensure a consistent and affordable supply of the medicines that are used in emergency care.

About the author

Raymond L. Fowler, MD, FACEP, FAEMS, is a professor of emergency medicine and emergency medical services at UT Southwestern. He is chief of the Division of Emergency Medical Services in the Department of Emergency Medicine and the James M. Atkins M.D. Distinguished Professor of Emergency Medical Services.