Gary Andolfatto spent four hours hobbling nine kilometres on one leg over snowy forest trails, using his bike as a crutch, after breaking his leg four years ago in a cycling mishap.
When Andolfatto, an emergency room doctor at Lions Gate Hospital, was discovered by Lynn Canyon park rangers and loaded into an ambulance, his immediate need was pain control.
Andolfatto was shocked when the paramedic riding in the back with him could only offer nitrous oxide, commonly referred to as laughing gas.
“He told me how frustrating it was that it is all primary care paramedics are permitted to give since they aren’t trained or permitted to inject drugs or give opioids,” said Andolfatto.
“I was ashamed, and felt so humbled that I didn’t realize what their limitations were and how bad it must be for them and their patients in serious pain. It really struck a chord and it gave me the impetus to do something that would be a game changer. Maybe I was meant to break my leg that day.”
Some innovators jot down the kernels for good ideas on napkins. While lying on a stretcher, with a broken left femur, Andolfatto conceived a research study that would involve paramedics spraying low doses of ketamine — a non-opioid, but still a controlled substance — into the nostrils of patients.
Unlike opioids like fentanyl, ketamine doesn’t suppress respiration so it is considered much safer.
“With low-dose ketamine, the risk of doing serious harm is zero,” said Andolfatto. “There are many reasons why it makes sense for this to be used more widely in an ambulance setting. On the other hand, laughing gas (delivered through a mask) requires a certain amount of co-operation (inhalation) from patients.”
Laughing gas is also not as effective as ketamine for controlling pain, added Andolfatto.
The research Andolfatto envisioned that day was recently published in the Annals of Emergency Medicine.
Now primary and advanced care paramedics with B.C. Emergency Health Services (BCEHS) are enthusiastically starting to deliver intranasal ketamine. Critical care paramedics with advanced training have been using intravenous ketamine on patients since 2008 but 70 per cent of the more than 4,000 paramedics in B.C. are at the primary care level and not permitted to do so.
The research led by Andolfatto has paved the way for use of a drug that is economical ($10 a dose), effective, safe and delivered quickly without needles, said Joe Acker, director of clinical and professional practice at BCEHS.
But before ketamine can be widely used by paramedics the provincial government will have to change statutes pertaining to the scope of practice of primary care paramedics as it is a controlled substance, said Acker. Health Canada will also have to give its approval.
BCEHS also has some challenging logistical issues to work on to prevent theft of ketamine by patients, paramedics or others. Biometric safes for storage and audits — similar to what hospitals have done to prevent drug diversion — are two of the strategies being implemented.
“The onus is now on us to do our due diligence,” Acker said, adding that paramedics have for too long been hampered when it comes to relieving pain experienced. In rural areas, such transports may take hours and when paramedics witness such pain, it can be traumatizing, “opening huge moral wounds for paramedics frustrated that they cannot offer more.”
The study involved 120 patients who were transferred by ambulance to Surrey Memorial Hospital between November 2017 and May 2018. Patients were randomized to receive either a ketamine nasal spray or a placebo of saline solution. Those who got ketamine, along with nitrous oxide, reported having a significant reduction in pain after 15 minutes. A majority of patients who got ketamine said they felt dizziness and a feeling of unreality, but their levels of comfort were higher than those who received a placebo spray into the nostrils.
“We now have the science to show us that it can be used effectively and safely by primary care paramedics,” Andolfatto said. “Now it’s time to allow primary care paramedics to start using it and doing the quality assurance piece to ensure it provides a real benefit, is financially feasible and won’t potentially be abused.”
The $26,000 study involved researchers from UBC, Lions Gate Hospital, Surrey Memorial Hospital, and BCEHS. It was funded by the Vancouver Coastal Health Research Institute and the B.C. Emergency Medicine Network.