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MCH details how drugs are tracked

Protocol makes thefts difficult

PETERBOROUGH — The case of a Peterborough paramedic accused of stealing narcotic drugs from Peterborough Fire Department ambulances, which is making its way through the court system, has opened new questions about access to drugs and the process for tracking such medications. While declining to comment specifically on the charges against former Peterborough Ambulance Service Clinical Director Jeremy Bouchard, officials at Monadnock Community Hospital and the Peterborough Fire Department, in separate interviews last week, described the safeguards intended to ensure that controlled drugs are used properly.

While the systems of checks and protocols don’t offer insight into the specific allegations against Bouchard (The 8th District Court in Jaffrey has yet to receive an affidavit in the case), the measures do underscore the difficulty anyone would have in illegally taking medications even once. Bouchard is accused of stealing medications between August of 2012 and this past August. He is due in court for a probable cause hearing on Tuesday.

Mike Flynn, the hospital’s director of pharmacy and oncology services, said Friday that the hospital’s system monitors distribution, access and use of medications. “Checks and balances, including locked systems and documentation, restrict access of medications to appropriately licensed personnel,” he said.

State guidelines determine how the drugs that are carried on ambulances may be used.

“The state’s EMS Medical Control Board has established a statewide series of protocols for each type of medical emergency,” said Flynn. “It gives people on the ambulances an understanding of how they can operate. The protocols establish who has what authority to give what medication.”

Flynn said there are now four tiers of people who respond to medical emergencies: first responders, emergency medical technicians (EMTs), advanced EMTs and paramedics. Paramedics have the highest level of training and are the only ambulance personnel authorized to administer narcotic drugs.

John Chisholm, who was recently appointed as interim clinical director for Peterborough Fire and Rescue, said the state patient-care protocols clearly indicate which medications can be used for various medical conditions and which ambulance personnel are able to use those medications.

“EMTs have a limited amount of medication they can use,” said Chisholm, who is a paramedic, on Saturday. “They can use oxygen, or issue aspirin, for example, or use an EpiPen. Advanced EMTs can do more. They can start IVs, use saline solutions, give some cardiac drugs and respiratory medications. Only paramedics can administer narcotics.”

Flynn said MCH contracts with a number of municipalities in the hospital’s coverage area to provide medications that are carried on ambulances. The hospital first follows state guidelines for what drugs to prescribe, but Dr. Craig Lauer, the physician in charge of the emergency department, can also make adjustments to that list.

“At the hospital, we determine what we will provide to the municipalities,” Flynn said.

While MCH supplies medications to many local rescue departments, the hospital provides controlled drug kits only to the four local ambulance services that transport patients to hospitals — Antrim Ambulance, Peterborough Fire and Rescue, Jaffrey-Rindge Memorial Ambulance and the Souhegan Valley Ambulance. The controlled drugs are delivered in sealed black boxes containing forms that paramedics must fill out showing exactly how the drugs were used. Inside are tubes of morphine sulfate and Diazepam (Valium) and vials of Midazolam and Fentanyl.

The kits are sealed with a yellow tag, and may only be picked up by a paramedic who is authorized by the ambulance service.

Flynn said the drug kits on the ambulances and the drugs inside are the property of the hospital.

“The drugs are always under the purview of the pharmacist in charge at the hospital,” he said. “They are under the care of the municipalities, but we still have oversight.”

Flynn said drug kits are only issued to the four ambulance services, not to individual paramedics, and the hospital checks photo IDs of the paramedics who pick up kits. The hospital’s agreements with the four ambulance services call for the kits to kept locked in a safe on the ambulances.

The drug kits contain both narcotics, used for treatment of pain, and drugs in the benzodiazepine classification, such a Midazolam and Valium, which are used for treatment of anxiety, seizures or panic attacks, according to Chisholm.

“The hospital assigns [the medications] to the ambulance and they are very closely tracked,” said Chisholm. “The tags on the boxes are controlled by the pharmacy.”

Chisholm said when he picks up a new drug kit at the hospital’s pharmacy, he does a physical check of the supplied drugs in the presence of a hospital pharmacist and verifies the seal numbers.

“The kit goes into a locked cabinet in our ambulance. The paramedics are the only ones who have access,” Chisholm said. “We keep a log of the pharmacy seals in the ambulance.

Chisholm said the seals on the boxes are checked by the paramedics at all shift changes, which occur every day at 8 a.m. and 8 p.m.

Chisholm and Peterborough Fire Chief Joseph Lenox said the ambulance service has about 15 paramedics, who are part of the total Fire Department roster of about 70 people.

“We have two paramedics on duty every day on the day shift and one paramedic for each night shift,” Chisholm said. Because Peterborough has three ambulances, Chisholm and Lenox said they will sometimes call in another paramedic if the others on duty have gone out on calls.

Only paramedics are authorized to administer the controlled drugs. If there is no paramedic on a particular ambulance call, the kits cannot be opened. Each ambulance has one controlled drug kit. There is no back-up kit kept at the fire station.

After a kit is opened, the paramedic has to fill out a form in the kit to indicate what drugs were used. If a full dosage was not given to a patient, paramedics are required, Flynn said, to dispose of the wasted portion. He said that frequently means ejecting the remaining drugs in a syringe in a way that renders them unusable. A witness is required to sign the form if any drugs are disposed of.

After the patient is treated and forms filled out, the drug kit is resealed with orange tags provided by the hospital.

Ambulance services are expected to deliver the used kit to the hospital’s pharmacy for replenishment within 24 hours of the call. Often that will occur once a patient is released into the emergency room, but the pharmacy, unlike the emergency room, is not open 24 hours a day. Flynn said that a busy ambulance service like Peterborough’s might exchange a kit, then have three calls before 7 a.m. the next day, which might require a kit to be opened more than once. Each time, corresponding paperwork is updated and new seals applied.

When the kits are turned in, a hospital pharmacist will do a count of the units in the kits, check the kit’s proof of use sheet and review the run sheets of the ambulance call before refilling the kits. Copies of the record sheets are kept at the hospital.

Paramedics have to follow protocols established by the Division of Fire Standards and Training and Emergency Medical Services when they administer narcotic drugs, which are mainly used to control pain. They do not need to check in with a medical doctor before treating a patient with a narcotic drug.

“For example, they can give up to three doses of Fentanyl in the field,,” Flynn said. “To do more, they have to call medical control — in our case the doctor in the emergency room — and get a verbal order.”

Chisholm said New Hampshire also tracks emergency medical treatments using a program called TEMSIS, which stands for Trauma and EMS Information System. A full report of every medical call, including drugs administered, is entered into the TEMSIS system after the call is complete. Chisholm said the reports can be viewed by ambulance service administrators and hospitals. Those who use TEMSIS have different levels of access in order to meet the guidelines of the Health Insurance Portability and Accountability Act, which provides confidentiality protection for patients.

Dave Anderson can be reached at 924-7172, ext. 233 or danderson@ledgertranscript.com. He’s on Twitter at @DaveAndersonMLT.

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