Name Address Occupation • Special Commission of Inquiry into the Drug 'Ice' STATEMENT OF Paul Barry Millard 9 May 2019 Paul Barry Millard Lismore Ambulance Station Paramedic On 9 May 2019, I, Paul Millard, state: 1. This statement made by me accurately sets out the evidence that I would be prepared, if necessary, to give in court as a witness. The statement is true to the best of my knowledge and belief and I make it knowing that, if it tendered in evidence, I will be liable to prosecution if I have wilfully stated in it anything that I know to be false, or do not believe to be true. Background 2. I have been employed by NSW Ambulance for almost 21 years. I am a registered paramedic and hold the clinical classification of intensive care paramedic. I have spent the last 15 years of my service attached to Lismore Ambulance Station and am also a local resident. 3. I understand the term amphetamine-type stimulants to refer to ICE, speed and all variants of meth-amphetamines. 4. Over a number of years, I have seen an increase in the number of patients who require sedation because of drug use. This may be because of amphetamine use however my source of information is usually the patient and drug affected patients do not always provide a reliable history. In my experience, the patients I am treating are often affected by a combination of poly-drugs. 5. I understand that any type of drug use can lead to a degradation of neuro- transmitters which in turn can lead to depressive type of illnesses or presentation. In my experience, users get a big high originally and then continually chase this because they never get the same result as originally. They may then end up SCII.002.017.0001
Transcript
Name
Address
Occupation
• Special Commission of Inquiry into the Drug 'Ice'
STATEMENT OF Paul Barry Millard
9 May 2019
Paul Barry Millard
Lismore Ambulance Station
Paramedic
On 9 May 2019, I, Paul Millard, state:
1. This statement made by me accurately sets out the evidence that I would be
prepared, if necessary, to give in court as a witness. The statement is true to the
best of my knowledge and belief and I make it knowing that, if it tendered in
evidence, I will be liable to prosecution if I have wilfully stated in it anything that I
know to be false, or do not believe to be true.
Background
2. I have been employed by NSW Ambulance for almost 21 years. I am a registered
paramedic and hold the clinical classification of intensive care paramedic. I have
spent the last 15 years of my service attached to Lismore Ambulance Station and am
also a local resident.
3. I understand the term amphetamine-type stimulants to refer to ICE, speed and all
variants of meth-amphetamines.
4. Over a number of years, I have seen an increase in the number of patients who
require sedation because of drug use. This may be because of amphetamine use
however my source of information is usually the patient and drug affected patients
do not always provide a reliable history. In my experience, the patients I am
treating are often affected by a combination of poly-drugs.
5. I understand that any type of drug use can lead to a degradation of neuro
transmitters which in turn can lead to depressive type of illnesses or presentation.
In my experience, users get a big high originally and then continually chase this
because they never get the same result as originally. They may then end up
SCII.002.017.0001
addicted and depressed and suffering from a mental illness. This type of drug use
can place a huge strain on the mental health capabilities of the local health district
(LHD).
6. I have seen patients involved in amphetamine drug use and their families become
dysfunctional. For example, I have seen Grandparents stepping in to assist with
children where the parents are addicted.
7. From my observation, the patients I treat in these types of situation are from low
socio-economic groups and I base this observation on their geographic location and
the type of homes that I attend. When the local music festivals are held there
appears to be a greater number of call outs to these amphetamine type incidents
and the patients are generally younger. In my experience, there is a high proportion
of these patients who are young aboriginal males.
8. Some patients will tell me what they have used but often the information comes from
the family member who has made the call for assistance from NSWA. I am trained
to gather as much information about the incident when attending and this includes
making considered observations of surroundings. These observations will sometimes
reveal what the patient has been taking.
9. Where a patient has used ICE, in my experience this has usually been administered
using a pipe, but I have also had reports from patients who rub the drugs into their
gums, swallow or inject it. The latter is normally where other amphetamines are
involved. I have seen patients with significant sores at injection sites.
Hanns/process
10. I would estimate where there has been amphetamine drug use, the main reasons for
the call are mental health concerns followed by aggressive behaviour and then
reckless behaviour.
11. It is usual for NSWA to request police attendance at these types of incidents for the
protection of both the attending paramedics and the patient themselves. I have to
say that the NSW Police Force are very good at dealing with mental health issues.
12. In probably 95% of cases, I transport the patient to hospital.
13. It is very rare that a patient would be transported to a justice facility, that is, a police
station. I can only think of a few Isolated incidents where the patient had assaulted
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someone and criminal charges were considered. In those few cases, the patients
were non-compliant but had no other medical issues. There are also situations
where a patient is arrested and held in police cells and NSWA is called to do an
assessment.
14. I have access to Lismore Base Hospital where the ED is 24 hours and there are 24
hour mental health facilities. Tweed Heads and Coffs Harbour Hospitals also have
available mental health facilities. Lismore Base Hospital also has the Richmond Clinic
- a mental health facility that can take juveniles and, a drug and alcohol
rehabilitation facility. Although I am aware of these facilities, NSWA only transports
patients to hospitals.
15. NSWA does not have the capacity to conduct toxicology screening. A patient's
history is formed from their self-report or information provided by others, such as
family members.
16. NSWA paramedics are able to use a Caution Note system. This involves paramedics
submitting information about a particular address which can then be uploaded onto
the Computer Aided Dispatch system. When a call is received on a later occasion
that involves that address, the system automatically provides the previous advice to
the Control Centre (Coard) and the information is forwarded to attending paramedics
via the Mobile Data Terminal (MDT) in the ambulance vehicle. The information does
not apply to a particular patient, just the address where the incident involving the
patient occurred. If a caution note comes up when I am tasked to attend an
address, I will ask Coard to obtain further information from the caller and if
necessary, I will request that the police to attend. In my experience, our Coard staff
are very good at obtaining further, important Information and I understand questions
about violence and weapons are standard questions that they are required to ask.
All this information forms part of the risk assessment I conduct of every scene I
attend.
17. Known information about amphetamine use by patients is provided to ED staff by
Ambulance officers. This information is provided because first, it forms part of the
patient's history and enables the treating professionals to provide the appropriate
treatment, and secondly, it provides a safety net for these staff if the patient has
been or could become violent or aggressive.
SCII.002.017.0003
18. I would probably attend a patient who is experiencing a psychotic episode from an
ICE overdose about twice a year. On those occasions 1 would use sedation and
restraint for the patient's safety. This is because sedation can take some time so
restraint may be required until the sedation has worked.
19. In these circumstances, handover to ED is not a problem because the patient has
been sedated and/or restrained and is being closely monitored.
20. I rely upon the following protocols when dealing with these patients:
Attachment A
Attachment B
Attachment C
Attachment D
Attachment E
Attachment F
Attachment G
Comorbidities
MH4 - Mental Health - Mechanical Restraint
MH6 - Behavioural Disturbance - Mental Health
MH1 - Mental Health Emergency
M28 - Behavioural Disturbance - Medical
Pharmacology 241 Droperidol
Pharmacology 219 Midazolam
Pharmacology 239 Ketamine
21. In my experience, commonly occurring comorbidities for patients experiencing or
suspected of amphetamine use include depresssion, psychosis, family breakdown,
and general mental health disorders.
Referrals and interventions
22. I transport patients to hospital for appropriate treatment and understand that
referrals can be made by hospital treating staff. About once a year I might refer a
patient to a general practitioner and make an appointment for them. This would be
a patient who has identified they have a problem, they don't want to go to hospital
and they have the capacity and competency to refuse transport.
23. I am aware that patients have access to a Mental Health Unit at Lismore hospital,
Drug & Alcohol Rehabilitation and, the Richmond Clinic.
24. I don't know of any circumstance where someone wanting access to mental health
services didn't get that access.
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Families
25. In my experience and as noted above, amphetamine use seems to make families
dysfunctional. I am aware of my obligations regarding mandatory reporting for
children at risk and have made reports in situations where I have found children in
the care of parents or carers affected by amphetamines.
26. I have attended domestic violence incidents where amphetamine use has been a
factor. Generally these have been instances of verbal abuse rather than physical and
appear to occur because the caller to NSWA was trying to obtain help for the patient
in circumstances where the patient didn't want assistance. I can't recall the last time
I attended a physical assault on a family member arising from a patient using
amphetamines. Verbal abuse is more frequent.
Custodial
27. The closest correctional centre to Lismore is Grafton and I am not required to attend
that facility. Corrective Services does maintain holding cells next door to the local
police station. On occasion I might attend there, but usually by the time the patient
is transferred to the custody of Corrective Services they are not drug affected
because they need to be medically cleared from the police cells prior to their transfer
to the other facility. I understand a registered nurse is available to conduct the
assessment, although I believe that position is not available 24/7. When I have
attended the Corrective Services holding cells, it is for a medical issue or because the
patient is depressed.
Workplace issues
28. I have received information and education about the presentation, treatment and risk
issues for dealing with patients under the influence of drugs. This training has
included amphetamines but also drug use generally. That training occurred during
my intensive care training and is also part of regular scheduled training.
29. Training in these issues is focussed on managing behavioural problems. NSWA trains
paramedics to understand that a patient may exhibit behavioural problems for three
main reasons: mental health; medical; or, trauma. In my experience, the training
really assisted me as a paramedic in how to treat and manage these patients.
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30. I consider that training is always essential, and should be done on a regular basis
because things are always changing. NSWA protocols on managing patients with
behavioural problems were recently updated. The updates were required to reflect
better treatment and care. Because of these recent updates, I do not think that
changes in this area are required.
General
31. The opportunity to make this statement has caused me to reflect on recent cases. In
my view, I would not consider that amphetamine use is an epidemic as has been
described. From my experience being called to incidents in the Lismore area,
amphetamine related incidents are reasonably rare. They are certainly not a daily
occurrence.
Signature of Pa£:
Signature of :tnu
Date ~
SCII.002.017.0006
PROTOCOL: MH4 MENTAL HEALTH - MECHANICAL RESTRAINT
This protocol is for use for mental health patients for whom control is necessary to facilitate specific treatment or to prevent an injury to themselves or others when verbal de-escalation and other strategies have failed to conta in the situation.
In order to use the Mechanical Restraint Device (MRD) the patient must be authorised under the mental Health Act 2007 by having either a Section 19 (519), or Section 20 (520), or Section 22 (522) or Section 24 (524) enacted on t hem (refer protocol MH3).
Note: • Any restriction on the liberty of patients and other people with a mental illness or mental
disorder and any interference with their rights, dignity and self-respect is to be kept to the minimum necessary under the circumstances.
• Restraint should only be used in the best interests of the patient when other means of control have failed.
• Once the restraint has been applied, the patient must be supervised at all times by a paramedic who has been issued with a written authority to exercise the powers granted under the Mental Health Act 2007
Procedure:
1. Assess the patient as per skill 104.13 and protocol MHl
2. Attempt to verbally de-escalate the patient and the situation
3. If de-escalation fails, ascertain if the patient has already been authorised under the Act per protocol MH3. If the patient has not been authorised enact 520 as per protocol MH3
4. If sedation is required refer to protocol MH6
5. Place the patient in the Mechanical Restraint Device (MRD) (Skill 112.5)
6. Document time of application and removal of the MRD and any adverse event that occurred (if applicable)
7. Transport the patient to a declared mental health facility . Continually reassess the need for the MRD throughout transport and remove/apply as required
8. Regularly repeat and document ABCD physical examinations and physiological observations in ~ order to identify trends in clinical deterioration ~
NSWAmbulanc~
If physical examinations and/or physiological observations cannot be taken, paramedics must ensure the reasons are documented on the clinical record
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SCII.002.017.0007
- PROTOCOL: MH4 MENTAL HEALTH - MECHANICAL RESTRAINT
Treat per specific protocol
• Search Pt if authorised (MHS) • Sedate Pt if authorised (MH6) • Call for backup if not authorised • Contact Control to request NSW Police
attendance if patient cannot be searched/ sedated safely
No
etermlnc need or p ysica restra nt to themselves or others
Yes
Attempt to verbally de-escalate the patient and the situation
No
Enact S20 (if Authorised under Protocol MH3) Call for backup if not authorised
Contact Control and request paramedic backup and/or police attendance
Apply MRD (Skill 112.5)
Regularly repeat and document ABCD physical examinations and physiological observations in order to identify trends, clinical deterioration
r"'! and/or response to treatment ~
Clinical documentation requirements
• Transport Pt to a declared Mental Health Facility • Continually reassess the need for the MRD throughout
the transport and take actions accordingly • Monitor observations and limb observation regularity
throughout the transfer
• Document time on and off for the MRD and document any adverse outcomes • If physical examinations and/or physiological observations cannot be taken paramedics must ensure the reasons are
documented
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SCII.002.017.0008
PROTOCOL: MHG BEHAVIOURAL DISTURBANCE- MENTAL HEALTH
This protocol is for use with a mental health patient when behavioural control is necessary to facilitate specific treatment and prevent injuries to themselves or others. In order for this protocol to be used the patient must be authorised under the Mental Health Act 2007 by a Section 19 (S19), Section 20 (520), Section 22 (S22) or Section 24 (524) .
Whilst the use of effective communication and de-escalation techniques remain the priority for behavioural management of all patients, the use of sedation and restraint may be necessary to facilitate assessment, treatment or safe transport to a declared mental health facility. This should be achieved in the least restrictive manner for the shortest duration according to the level of risk. Any patient that requires restraint must be monitored for clinical deterioration {e.g. respiratory depression).
Caution should be taken with the elderly and patients with limited physiological reserves as adverse effects may occur at low doses.
Treatment:
1. Assess patient's mental health status (MHl) and identify potential suspected causes for patient's behavioural disturbance: • Medical (organic) cause: Always consider and treat organic causes (e.g. Hypoxia) of the
behavioural emergency - refer to protocol M28 (Behavioural Disturbance - Medical) • Trauma: refer to protocol T24 (Behavioural Disturbance - Trauma) • Mental Illness/Mentally Disordered: Determine the need for sedation
2. Attempt verbal de-escalation of the situation (if safe)
3. Confirm if patient is authorised under the Mental Health Act 2007 (MHA 2007), refer to protocol MH3 - If the patient is not already authorised paramedics must complete a S20
4. Consider restraining the patient: • Physical control - Police assistance should be requested in all situations where physical restraint
is required • Consider mechanical restraint (Protocol MH4) • Paramedics must remain vigilant and visually monitor the patient for signs of deterioration whilst
restrained 5. Sedate patient: The aim of sedation in behaviourally disturbed patients is to reduce the risk of
harm and to facilitate assessment, treatment and transport to hospital. Sedation should always be titrated to the point of reusable sleep only, not unconsciousness. Administer medications as indicated: • Droperidol (241) - Patients 2! 14 • Midazolam (219) - Patients< 14 and/or if droperidol ineffective and/or paramedic is not
authorised to administer droperidol • Note: Patients who are physically violent may be administered a single dose of midazolam in
between the initial and repeat dose of droperidol if indicated 6. Regularly repeat and document ABCD physical examinations and physiological observations in ~ order to identify trends in clinical deterioration ~
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SCII.002.017.0009
PROTOCOL: MH6 BEHAVIOURAL DISTURBANCE - MENTAL HEALTH
Assess patient's mental health status {MHl) and identify potentia suspected cause/ s for patient's behavioural disturbance
No
Treat per specific protocol : • M28- Behavioural Disturbance - Medical • T24- Behavioural Disturbance - Trauma
Attempt verbal de-escalation of the situation {if safe)
Yes Treat per specific protocol !4---<
No
Confirm if Pt is Authorised under Mental Health Act 2007 {MHA 2007)
{Protocol MH3)
Enact 520 (if authorised - Protocol MH3} Call for backup if not authorised
Cons, er restraining patient: • Physical control - Police assistance should be requested in
all situations where physical restraint is required . • Mechanical restraint- Protocol MH4 (if authorised)
Paramedics must remain vigilant and visually monitor the atient for si ns of deterioration whilst restrained
Sedate patient: The aim of sedation is to reduce the risk of harm and to facilitate assessment, treatment and transport to hospital. Sedation should always be titrated to the point of rousable sleep only, not unconsciousness:
• Administer medications as indicated : • Droperidol (241) - Patients~ 14 years of age • Midazolam {219) - Patients< 14 and/or if droperidol ls contraindicated and/or ineffective
or the paramedic is not authorised to administer droperidol Note: Patients who are physically violent may be administered a single dose of midazolam
in between the initial and repeat dose of droperidol if indicated
Regularly repeat and document ABCD physical examinations and physiological observations in order to identify trends, clinical deterioration ~ and/or response to treatment _
• Search Pt if indicated and authorised{Skill 104.13.1) • Transport Pt to a declared Mental Health Facility
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SCII.002.017.0010
- PROTOCOL: MHl
Procedure:
MENTAL HEALTH EMERGENCY
1. Safety of the paramedic, patient and bystanders is the key priority. • Always consider organic causes for the patient's presentation (e.g. hypoxia, hypoglycaemia etc.)
2. Scene assessment commences as soon as visual contact is made with the scene (Skill 104.13)
If the scene appears to be a safety risk or you suspect weapons may be present, stand off and call for immediate police assistance
3. Establish rapport: • Calmly identify yourself to the patient • Ask the patient's name and main concerns • Reassure the patient • Effectively communicate with simple words and sentences
Communication and verbal de-escalation is the first line management of people with behavioural disturbance
4. Perform a MENTAL HEALTH ASSESSMENT (using the STATE acronym) of the patient's current STATE of mental health and document on the clinical record
- Mandatory for all MH 1 Patients refer to skill 104.13
• Signs and symptoms that indicate an abnormal state of mental health including agitated behaviour
• Thoughts that indicate delusions, hallucinations, suicidal ideas or illogical thinking
• Appearance of the patient • Threats or acts by the patient that are potentially harmful to self or others • Emotions of the patient that indicate feelings of sadness, distress, anger or hopelessness
• Consult family and friends to establish if the current behaviour is out of character, how long it has bee·n evident and what coping mechanisms are usually deployed
• Document completion of the assessment and findings on the clinical record
5. Assess for clozapine toxicity. Clozapine is an effective anti psychotic for the management of treatment resistant schizophrenia. It has a narrow therapeutic index and significant toxic side effects. In patients taking clozapine, cessation of smoking can cause toxicity. Ask the patient if: • They are currently taking clozapine • They have recently stopped smoking or reduced the number of cigarettes smoked
If yes to both questions, assess patient for signs of toxicity • If toxicity is suspected or a patient taking clozapine has recently ceased smoking it is vital that
this information is included in the clinical handover
Signs of clozapine toxicity:
• Sedation • Hypotension • Hypersalivation • Akathisia (Restless Leg Syndrome) • Neurological adverse effects including seizures
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SCII.002.017.0011
- PROTOCOL: MHl MENTAL HEALTH EMERGENCY
6. If at patient is at risk of suicide - Refer Protocol MH2
7. Patient management if indicated (Protocol MH6 and Skill 104.13)
8. Determine patient disposition
• Transport principles - As per Urgent Transport Protocol A8 and the Memorandum of Understanding for Mental Health
• If the patient is co-operative, ensure that a minimum of 2 sets of ABCD physical examinations and physiological observations are made and recorded on the Clinical Record. If the patient objects to observations being taken, record the reason on the Clinical Record and observe the patient
• Section 20 (S20) of the Mental Health Act 2007 - if the mental health assessment indicates the need for the patient to be taken to hospital for further assessment and the patient refuses to come voluntarily, S20 may be used to take the patient to hospital against their will. S20 must also be enacted if the patient is going to be restrained, sedated or searched . Patients being transported under S20 of the Act must be taken to a Declared Mental Health Facility - Refer to Protocol MH3
• Document on the clinical record that a mental health assessment has been conducted (including if powers under the Mental Health Act 2007 have been enacted)
The Mental Health Line (1800 011 511) is available 24/7 for the community (including paramedics) to call for advice on mental health related issues.
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SCII.002.017.0012
- PROTOCOL: M28 BEHAVIOURAL DISTURBANCE -MEDICAL
Protocol M28 is for use with any patient where behavioural control is required because of a known or suspected medical condition to facilitate assessment, treatment and/or transport . The aim is to prevent injury to the patient, paramedics or others.
• If the patient is mentally ill or mentally disordered and requires an in-hospital mental health review refer to protocol MH3 and MH6
• If the suspected cause of the acute severe behavioural disturbance is trauma related (i.e. head injury) refer to protocol T24
Various medical conditions may present with altered behaviour requiring management of acute severe behavioural disturbance (MASBD). While treatment of the underlying condition may be the key to resolving behavioural disturbance, in conjunction with effective communication and de-escalation techniques, some patients may also require sedation to facilitate assessment, treatment or safe transport.
Where sedation of patients with a medical condition is required, paramedics should aim to achieve this in the least restrictive manner for the shortest duration according to the level of risk. Caution should be taken with the elderly and patients with limited physiological reserves as adverse effects may occur at low doses. Therefore patients 2:: 65 years of age must receive half doses to reduce the risk of adverse effects.
Treatment: Determine the need for sedation and/or restraint for Acute
Treat per specific protocol • Behavioural Disturbance - Mental Health MH6 • Behavioural Disturbance - Trauma T24
Assess and treat potential organic causes per specific protocol (e.g. hypoxia, hypoglycaemia, sepsis etc)
Transport to ED _ __ _,,, Regularly repeat and document ABCD physical examinations and physiological observations in order to identify trends, clinical deterioration
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SCII.002.017.0013
PHARMACOLOGY: 241
Generic Name: Droperidol
Type: Neuroleptic
Action: • Droperidol produces marked tranquilisation and sedation May -J; BP due to direct vasodilatory effect and alpha block
DROPERIDOL
• Droperidol potentiates other CNS depressants, e.g. narcotic analgesics such as fentanyl and benzodiazepines such as midazolam
fever, hyperthermia, altered consciousness and autonomic instability)
Contraindications: • Patients with known or suspected hypersensitivity to droperidol Patients < 14 years of age Patients with Parkinson's Disease
Preparation: • 10mg (2ml) vial (DORM™)
Dose
Notes: • Paramedics are authorised (if indicated) to administer a single dose of midazolam (219) in between the initial and repeat doses of droperidol under protocols M28 and MH6 ONLY if the patient is physically aggressive If indications persist 15 minutes post the 2nd bolus of droperidol, authorised paramedics may administer midazolam (Pl,ALS,ICP) or ketamine (ALS,ICP) per current pharmacology regimens for the management of behavioural disturbance
• Ketamine is the preferred medication for patients with a suspected acute traumatic brain injury requiring management for behavioural disturbance. Where ketamine is not available and/or contraindicated paramedics may administer droperidol
• IV administration of droperidol is authorised during transport to hospital and/ or during inter-facility transports if an IVC is already insitu
Initial Dose Repeat Max Total Dose '
BEHAVIOURAL DISTURBANCE - ALL INDICATIONS Indication - Patients~ 14 years of age *Patients~ 65 years of age and/or patients with limited physiological reserves must receive a reduced dose
~ 14 - < 65 Pl+4 IM/IV 10mg bolus Once after 15 min 20mg
~ 65* Pl+4 IM/IV 5mg bolus Once after 15 min 10mg
Note: IV administration of droperidol is authorised during t ransport to hospital and/or during interfacilit y t ransfe rs if an IVC is already insitu
Clink 11I Level Key: 1- Geographica l Areas-Auth Pa ra medics Only, 2 • Under a pproved circumsta nces, J - AL5 & ICP who have comple ted Pl tra ining, 4
• Pl paramedics on completion of training package
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SCII.002.017.0014
PHARMACOLOGY: 219 MIDAZOLAM
Generic Name: Midazolam
Type: Benzodiazepine
Action: • An anticonvulsant with anxiolytic and amnesic effects
• T16 - Limb Realignment and/or Difficult Extrication • Behavioural Disturbance - Medical (M28), Trauma (T24), Mental Health (MH6)
Post Intubation Sedation (~ 6 months of age only) Distressing Psychological Reactions Post Ketamine Administration
Adverse Effects: • ..!, LOC resulting in upper airway obstruction Respiratory and cardiovascular depression which may be exacerbated in patients with limited physiological reserves and/or under the influence of alcohol or drugs
Contraindications: • Nil for NSW Ambulance
Preparation: •
Notes: •
Dose
5mg (1ml) ampoule • Dilution 5mg (1ml) diluted with 4ml NaCl to a total volume of 5ml(lmg:lml)
This pharmacology contains full dose regimens. Consideration should be given to the administration of half the stated dose to patients with limited physiological reserves, advanced age, smaller than average size or general debility Paramedics are authorised (if indicated) to administer a single dose of midazolam (219) in between the initial and repeat dose of droperidol under protocols M28 and MH6 ONLY if the patient is physically aggressive
LIMB REALIGNMENT AND/OR DIFFICULT EXTRICATION Indication - To facilitate limb realignment and/or difficult extrication post analgesia to provide effective pain
management at rest for the patient
~ 10 - <65 ALS+ IV 1mg diluted bolus 3 min 5mg
~ 65 ALS+ IV 0.5mg diluted bolus 3 min 2.5mg
dink:11 l evel Key: 1- Geogra phtca l Areas- Auth Par.amedks Only, 1
- Unde r approved circumstances, l - AL.S & \cP who have completed Pl training, 4• Pl paramedics on completion of training p,1ckage
e NSWAmbLLllnU
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SCII.002.017.0015
PHARMACOLOGY: 219 MIDAZOLAM
~ 16 Pl+ IM 5mg undiluted bolus
~ 16 Pl+ IV 2.5mg diluted slow bolus
0.3mg/kg undiluted bolus via < 16 Pl,ALS3,ICP3 IN Mucosal Atomising Device (MAD)
(Max bolus: 5mg)
< 16 Pl+ IM O.lSmg/kg undiluted bolus
(Max bolus : 5mg)
< 16 Pl+ IV/10 O.lSmg/kg diluted bolus
(Max bolus: 2.5mg)
BEHAVIOURAL DISTURBANCE Indication -
5 min 15mg
5 min 15mg
0.3mg/kg Nil
(Up to 5mg)
5 min 0.4Smg/kg
(Up to 15mg)
5 min 0.45mg/kg
(Up to 15mg)
. Non Head injured patients where droperidol is ineffective 15 minutes after the maximum total dose or is
contraindicated (Pl", ALS, ICP Only)
. Acute traumatic brain injured patients where ketamine is ineffective or contraindicated for use
Paramedics are authorised (if indicated) to administer a single dose of midazolam (219) in between the
initial and repeat dose of droperidol under protocols M28 and MH6 ONL V if the patient is physically
aggressive
~ 14 - <65 Pl+ IM 5 - 10mg undiluted bolus 5 min 15mg
~ 14 - <65 Pl+ IV 2.5mg diluted slow bolus 3 min 15mg
~ 65 Pl+ IM 2.5 - 5mg undiluted bolus 5 min 7.5mg
~ 65 Pl+ IV 1.25mg diluted slow bolus 5 min 7.5mg
< 14 Pl+ IM O.lSmg/kg undiluted bolus
5 min 0.45mg/kg
(Max Bolus: 5mg) (Up to 15mg)
< 14 Pl+ IV O.lSmg/kg diluted slow bolus
3min 0.4Smg/kg
(Max Bolus: 2.5mg) (Up to 15mg)
d lnk al Leve l Ke y: 1- Geographica l Area s- Au th Paramedics Only, 2
- Under approved circumstances, 3- Al.S & ICP who have completed Pl training, 4
- Pl paramedics on completion of training package
NSWAmbulentt
Revised: OS July 2018 Page 2 of3 Approved by: Execu tive Director Clinical Systems Integration
Maintained by: Clinical Systems Integration 2018 Protocol and Pharmacolorv
Note: The most current 11ersion of this document is avallable on the NSW Ambulance CJinlcaJ Systems ,ntegration Intranet. Document is uncontrolJed when printed. 249
SCII.002.017.0016
PHARMACOLOGY: 219 MIDAZOLAM
Dose continued
Patient Initial Dose Max Total Dose
POST INTUBATION/LMA SEDATION Preparation : 10mg ()llll) 1111dawlam 1111xer! w ith 10mg 11 ml I lllOI ph1ne ,111<! dil11tPd w1 tl 1 /ml ,odium d1l011dp
O.<n_. to 10ml total volu111e Mo, ph111e/M1darnla111 ,o lu t1011 J ml - 1mg 1111dawla111 + 1mg 1ll[Jrf)ht11,··
NOTE: IV Regimen for Post lntubation/LMA Sedation may be repeated ZO minutes after the last administration
~ 16 ICP IV 2.5ml morphine/midazolam
3 min 15ml solution bolus
5ml morphine/midazolam ~ 16 ICP IM solution bolus if IV not 15 min 15ml
available
O.lml/kg morphine/midazolam 0.3ml/kg
~ 6 months - < 16 ICP IV/I0 solution bolus 3 min (Up to 15ml)
(Max bolus: 2.5ml)
O.lml/kg morphine/midazolam 0.3mL/kg
~ 6 months - < 16 ICP IM solution bolus if IV not available 15 min (Max bolus: 2.5ml)
(Up to 15ml)
Clinical l evel Key: 1- Geogra phical Areas-Au th Pa ramedics Only, 1- Und er approved circumstances. 3
• Al.5 & ICP who have comple ted Pl tra ining, 4 - Pl paramedics on completion of training package
Revisl!d: OS July 2018 Page 3of3 Approved by: Executive Director Clinical Systems Integration
Maintained by: Clinical Systems Integration 2018 Proto<ol•_nd l1J'11rmK olol"f
Note: The most currrnt version ofth(s documerit is ovaifabfe on the NSWAmbu/ance Cffnfcaf Systems Integration Intranet. Document is uncontrolled when printed. 250
SCII.002.017.0017
- PHARMACOLOGY: 239
Generic Name: Ketamine hydrochloride
KETAMINE
Type: Dissociative anaesthetic agent with analgesic effects
Action: • Dissociates the central nervous system from painful stimuli. At low doses ketamine causes a trance like state characterised by analgesia and amnesia with retention of protective airway reflexes, spontaneous respirations and cardiovascular activity
Route Onset Peak Duration
IV 30 - 90 seconds < 5 minutes 10 - 15 minutes
IM 3 - 5 minutes 10 - 15 minutes 15 - 30 minutes
Use: • AG - Pain management • Behavioural disturbance - Trauma (T24}, Medical (M28}
• Nausea & vomiting • Muscle effects including increased tone, random purposeless movements
Contraindications: • Suspected or known allergy to ketamine • Patients with known or suspected history of psychosis • Patients < 14 years of age • Known 1st or 2nd trimester pregnancy
Preparation: • 200mg (2ml} vial • 200mg (2ml} diluted to 20ml (l0mg:lml) with 18ml NaCl
Notes: • Patients who are experiencing distressing psychological effects (e.g. agitation, hallucinations and/or dysphoria} post administration of ketamine and who are unresponsive to reassurance may be administered 0.5 - 1mg IV diluted midazolam (219} as a single bolus dose
Dose
Initial Dose . - ... Max Total Dose
ALL USES
- Ketamine regimen may be repeated &O minutes after last administration Indication - Pain management & management of behavioural disturbance in patients with a suspected acute traumatic brain injury
- Under approved circumslances. 1• Al5 & ICP who have completed Pl training, • - Pl paramedics on completion of training package
Revised: July 2018 Pagelofl Approved by: Executive Director Clinical Systems Integration
Maintained by: Clinical Systems Integration 2018 Protocol and Pharmacology
Note: The most current version of this document is available on the NSW Ambulance Cllnlcal Sy.Jtems lnteflrutfOn Intranet. Document is uMontrolled when printed. 243
SCII.002.017.0018
PHARMACOLOGY: 239 KETAMINE
IV Ketamine Dose:
• Dosages have been rounded to the nearest 0.5ml volume for ease of administration via 20ml syringe
• Paramedics may decant the exact weight based dose by 1ml, 3ml or 5ml syringe and drawing up needle in lieu of rounded administration to administer exact weight based dose
IV (Rounded) Weight Based Dosage Table
Age Weight (Kg) Dose (mg) Vol (ml) Age Weight (Kg) Dose (mg) Vol (ml)
40 - < 60 10 1 42 - < 65 5 0.5
60 - < 75 15 1.5 ~65 65 - < 115 10 1
~ 14 - < 65 75 - < 100 20 2 115+ 15 1.5
100 - < 115 25 2.5
115+ 30 3
IM Weight Based Dosage Table
Age Weight (Kg) Dose (mg) Vol(ml) Age Weight (Kg) Dose (mg) Vol (ml)
- Under apprnved circumstances, 1 - ALS & ICP who have completed Pl training, 4
• Pl paramedics on completion of training package
e NSWAmbulanN
Revised: July 2018 Page 2 of2 Approved by: E1eecutive Director Clinical Systems Integration
Maintained by: Clinical Systems Integration 2018 Protocol and Pharmacology
Note: The most cur,ent version of this document is availobfe on the NSW Ambulance Clinical Sy.stems Integration Intranet. Document is uncontrolled when printed. '"
