Due to known patching issues inhibited by the currently required PPE can the OBHG look at omitting mandatory patch points specifically surrounding Midazolam and Ketamine administration for combative and excited delirium patients. I have never been denied an order for either of these medications and the time required to call for an order increases the risk of injury to everyone involved with the extra time required to complete the call delaying treatment. Second question, can we also look at increasing the maximum dose of Midazolam to 10 mg for combative patients as I have found that often times 5mg is insufficient especially when used on patients with known drug abuse. Or, is it possible for the OBHG to considering opening up Ketamine to be used on combative patients, as its my understanding Ketamine is a safer drug with less side effects?

We understand the difficulty with communication and currently required PPE and in this patient population, This is why SWORBHP released a memo (here) with regards to current difficulties in bi-directional communication between paramedics and patch physicians due to concurrent PPE use and how to proceed in these situations whereby communication is impeded.

We are pleased to hear that sedation orders have always been provided to you.  However, that is not always the case.  There are multiple instances whereby sedation orders have not been given or alternative strategies developed between the paramedic and patch physician.  That being said, future iterations of the combative patient medical directive will no longer have a mandatory patch point for midazolam. Until its release, paramedics should continue to follow the in-force version of the ALS PCS.

Ketamine is not without its own complications, and some of those complications including laryngospasm are more critical than those of midazolam.  As such, midazolam remains the agent of choice for the majority of combative patients and ketamine is reserved for patients with excited delirium and violent psychosis.

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