The Normal Saline Shortage and the ALS Mindset

In case you haven’t heard, the United States is running short of slightly salty water. Specifically we’re having an unprecedented shortage of 0.9% normal saline solution, the kind that is used as the most common intravenous fluid in every form of healthcare that puts needles into people’s veins. I don’t really know the reasons why our country is unable to produce enough sterile bags of the stuff that covers the vast majority of our planet, but we cannot seem to get enough to slake our proverbial thirst for it. Ergo, many hospitals and ambulance services are finding their supplies on indefinite backorder and are having to find workarounds for the problem. It’s not good, and it doesn’t look like the shortage is abating anytime soon.

I know there's gotta be salty water around here somewhere...

I know there’s gotta be salty water around here somewhere…

I was thinking about this the other day while picking up a prescription at the local pharmacy. As I was paying the tab, the pharmacist asked, “Is there anything else I can help you with today?

“Yeah” I replied, “got any normal saline IV solution in the back? I was only half kidding.

“Why are all you healthcare types asking me if I have any salt water?” He fired back, genuinely looking perplexed.

The saline shortage has brought a change in protocol at my ambulance service. It used to be that every patient who received an IV had it attached to a liter bag of normal saline from our IV fluid warmer. Every IV, every time. Even though we all knew that the majority of these IVs were not going to be used for much of any purpose at all except for the few used as medication ports and as access for drawing blood for laboratory work. As such, most of the now-precious salt water we were using in the past was dumped straight down the drain after the patient’s hospital treatment had ended. Generally, since our IV sets are not the same as those used by any of the 5 hospitals in our region, the patients requiring longer-term IV drips had our bags of saline and administration sets swapped out as soon as they were needed by the inpatient units.

This may seem wasteful or unnecessary to the non-healthcare folks reading this, but I assure you that the inexpensiveness of the equipment used coupled with the relative safety of establishing an IV for access in potentially serious medical conditions makes sense, or at least it did when salt and water were plentiful and cheap.

Now days we’ve changed our practice in response to the shortage and are doing the following:

  1. We are not starting an IV simply for the convenience of the Emergency Department staff. If they want to use their saline, that’s great. They can procure it and pay for it. We don’t get reimbursed for it in our fee schedule and they have more purchasing power than we as a single ambulance service ever could.
  2. If a patient needs IV access for medications or as a precaution should fluids or medications likely become emergently required, we are starting a saline lock that is not attached to a 1000ml bag.
  3. Only patients who require fluid resuscitation are being hooked up to big bags of fluid. If they’re not going to need it, they’re not getting it.

This is a pretty darn smart policy change in my opinion, and I like that this is our plan of action to get through the shortage. I do have to admit that this change required me to change my thought process a little bit though. Back when I started doing this whole paramedic thing (Can I invent the word paramedicking? Can that be a thing?) Some people were using the term ALS as a verb. I would hear providers use the term the patient has been fully ALS’d, by which they meant the patient had gotten an IV, was being given oxygen, and had been placed on a heart monitor. I used to use the term a full tune-up and lube job when communicating with my partners that I’d like the whole o2, IV, monitor routine done to the patient in our care. It seems kind of silly now, but it was what pretty much all of us used to do back then. While today we’re vastly cutting the number of times we jab anyone with a needle and are only giving oxygen to patients with verifiable hypoxia, it didn’t used to be like that back in the day. Oh, and before you ask, this isn’t because of the economy or Obamacare or any other political reason, it just makes solid sense.

So if we’re not doing the o2, IV, monitor thing that used to be popularly identified as being the hallmarks of ALS care, are we really providing Advanced Life Support as paramedics? Will our BLS counterparts accuse us paragods of not doing anything different for our patients?

No. Because, just like Dr. Scalea said of Critical Care, ALS is a mindset.

Advanced Life Support isn’t about what you do, it’s about what you know and how you use that knowledge. It is not a set of skills that can be performed by monkeys who have been taught how to effectively poke people with needles and intubate things, it is a body of knowledge, training, education, and experience that is earned by clinicians who have learned how to function within their role as a clinician. You can train someone off the street how to insert an IV and how to slap on a non-rebreather mask and a monitor but you aren’t making them an ALS provider. Knowing how and when to use the skills judiciously and properly is what makes an EMT or Paramedic an ALS provider as opposed to a skill-monkey blindly following a protocol.

While I tend to fancy myself as a clinician, it took a shortage of salt water to help me be able to put these thoughts into words.

Old EMS used to be about blindly following a protocol, and while there has been solid evidence coming from other industries, such as aviation, that show that checklists help with ensuring tasks are completed to quality standards under pressure, the checklists don’t replace highly trained pilots with experience and education behind them. Nor do protocols replace a good clinician. New EMS is about providing a patient with the right care for their condition based upon evidence that proves how that care actually helps them. Old EMS was a vast leap forward from the non-systems that it replaced, but it still held on tightly to things like the Cult of the Mechanism of Injury, or the Plastic Snake Oil that I call the backboard and C-collar. Those things haven’t been shown to help anyone and may actually hurt people, yet we used to blindly accept them as dogma because we were all taught to do so.

Just like I had been taught back in the day to start an IV because they’re going to get one at the hospital anyway.

To be sure, if I believe something is medically necessary I am going to do it for the patient. I would never withhold care when it is appropriate and needed for any reasons where the benefits outweighed the risks.

I just think it’s notable that a shortage of something caused our industry to start looking at things differently and to move towards weighing treatment based upon benefits to the patient rather than benefits to a hard protocol.

I wonder what we’ll run short on next.*

* I hope it’s backboards

  • Christopher

    I never understood why saline locks were NOT the norm at services.

  • i love saline locks. it never gets caught on anything and yanked out accidentally.

  • fedup

    ANYONE can be a PROTOCOL Medic. Break outside of the protocol thought process and expand your profession. That’s part of our problem as a whole. And people wonder why EMS is a stepping stone.

  • christine

    We’ve been using NS licks at the company I work with for many years and wthey’re wonderful. Originally working in a “mother may I?” state, I would call a medIical ontrol physician write to call saying I have been dispatched to…and would like orders for full ACLS/PALS/… so I could do whatever I needed to do for the patients without worrying about the protocols and more we are trusted enough that protocols are guidelines or recommendations, but each patient and call is unique.

  • Tim

    I never liked the term “protocol monkey.” Protocols should be what other industries refer to as ‘best practices.’ Okay, Protocols can’t anticipate everything, I’m not saying you can never deviate from them, just saying that deviation should generally be done with a good reason. I’ve had lots of good reasons to bend policy and protocol, and never been seriously in the wrong for doing so, but Ive also done some dumb but not harmful things because the protocol book said so. Doesn’t it lead to better consistent and scientifically valid care, if we generally follow the rule book, or to change to rule book.

  • Rescue Monkey

    Why would you place a 1 L bag of saline on EVERY IV you start? What a waste of resources.

  • Alex

    One of the 3 companies that were making the liter bags of NS stopped production, thus causing the shortage.

  • We rarely use NS on patients unless it’s indicated. I don’t even start IVs on half my patients. I have to have good reason to believe they’re sick or to think that the hospital will want labs to rule out the person not being sick.

    On the note of hospitals, the tables are turned here. Our ban-aid box asked us to supply them with NS bags at one point. Guess that’s just because we’re a large national EMS company.

  • John

    And it’s not the Normal Saline itself that is in short supply, it’s the packaging while the facilities are being retooled.

  • Kevin McDonald

    Hell yeah….love it. No more “cookbook” medics.

  • Matt

    Waste or no, a saline lock and a 10 mL flush cost more than a 1 L bag and a macro drip set.

  • Sam

    a good Pulse/Ox will ususally suffice if there are no obvious critical, trauma issues and the person only needs transport