Toradol Use Gets a Nod from the State

QA truck

Brewster's Toradol Pilot Program a Win for the State

Back in April, 2017, we published an article covering Brewster Ambulance's Toradol pilot program. In the article, we wrote that for over a year Brewster Ambulance has been lobbying the Massachusetts State Department of Public Health to offer an alternative source of pain management when caring for patients. After a lengthy approval process to run a special pilot program through the Office of Emergency Medical Services, Brewster Ambulance was granted an Advanced Life Support procedure for intramuscular and/or intravenous administration of Ketorolac Tromethamine (Toradol) as an alternative non-narcotic analgesic. 

Brewster Ambulance proposed this non-opiate based analgesic for patients suffering from acute moderate to severe pain as an alternative to opiate administration, and was the first EMS service in the Commonwealth to provide this option. This program was designed to address a specific demographic of people from 18 to 65 and did not include the pediatric population. Offering Toradol equipped Brewster Ambulance with a pain medication choice for patients—a choice that aligned with Governor Baker's new anti-opioid abuse legislation and task force. This story was also covered by Boston's Fox 25 News.

  Brewster Ambulance Service President and CEO, Mark Brewster with Massachusetts Governor Charlie Baker

Brewster Ambulance Service President and CEO, Mark Brewster with Massachusetts Governor Charlie Baker

State Pain Medication Protocol now official

On September 23rd, 2017, Massachusetts state health officials approved the use of IV Tylenol during hospital transports as an alternative pain medication on ambulances. Now official state-wide, this medication protocol will allow paramedics to administer three alternative non-narcotic pain medications to patients treated and transported on ambulances, which can then be continued at the hospital. These medications include:

  • Acetaminophen (Tylenol) given orally (P/O) or intravenously (IV)
  • Motrin
  • An intramuscular (IM) or intravenous (IV) option of Ketorolac Tromethamine (Toradol)

Prior to this new protocol, the only remedy on ambulances for pain medication was fentanyl, which has a host of associated risks from patient addiction (and abuse) to contact exposure of first responders. This protocol now afford an option for patients who either don't want to risk addiction or who may be recovering from addiction whereas in the past, there was not an option for pain management.

Many EMS agencies and ambulance companies also joined Brewster in promoting this protocol to become a state mandate, including the Acushnet Fire Department, who created a social media campaign to generate awareness and support from over 70,000 Facebook users.

Mark Miller, Director of the Office of Emergency Medical Services and Jon Burstein, State EMS Medical Director released an update on September 26, 2017 regarding the Emergency Non-Opioid Pain Treatment Options. In it, they state: 

The Office of Emergency Medical Services (OEMS) and the Medical Services Committee (MSC) recently conducted a review of the pain treatment options that are carried on paramedic level advanced life support (ALS) ambulances. This process, which included review of the Drug Formulary Commission’s list1 of non-opioid drug products that are effective pain management alternatives, uncovered that there is a gap in the current treatment for pain related issues. There is an apparent need to increase the number of non-opioid options for all patients, while still remembering that ice, padding of injuries, positioning for comfort and hand-holding are valuable skills of our EMS personnel.
In response, the MSC voted to recommend that OEMS issue an emergency protocol change to allow the use of three non-opioid medications: ketorolac, acetaminophen, and ibuprofen. These medications will increase the number of pain relieving choices for EMS and meet the need for a non-opioid pain treatment pathway. This recommendation has been accepted by OEMS and the Department of Public Health.
The new medications listed below have been added to the Massachusetts Statewide Treatment Protocols, effective immediately, and are available to be implemented immediately with training on this protocol as approved by their affiliate hospital medical director. These medications should assist EMS with addressing a patient’s pain and making sure the right medications for various aspects of pain and discomfort are available. The intention of these additions is to encourage safe thoughtful administration of the medication that provides the best reductions in pain and discomfort while allowing for better patient-directed treatment.
The following medications will be required on paramedic ambulances, with minimum supply quantities as noted, beginning January 1, 2018. The attached updated Protocol 2.13 for Pain and Nausea Management, Version 2016.3, provides dosing, relative contraindications and contraindications. Medical Control can always be contacted to help answer questions regarding a particular patient.
Ibuprofen PO: Bottle or individually wrapped. 1200 mg minimum
Acetaminophen PO: Bottle or individually wrapped. 2000 mg minimum
Ketorolac IV or IM: 60 mg
The following medication is optional until further notice: Acetaminophen IV: 2000 mg minimum
Pain and Nausea chart

At Brewster Ambulance, we will always seek better solutions for our patients and first responder safety, while improving the opportunities for health and wellness throughout the communities we serve. We celebrate this new patient choice for pain management option, and are proud that we were able to create the pilot program that helped provide the state evidence that the program had value to patients.

We are committed to improving EMS delivery at all levels of service, through enhanced technology, training and clinical protocols.

Additional resources can be found in the following links: