Happy Sunday! I have a few small logistical updates, and some education.

1. MBC Has Narcotics Now
2. Hands on in the Clinic
3. Call For Orthopedic Questions!
4. How to Call the Clinic
5. Ibuprofen and Tylenol Pill Pack Education
   1. Some background on the meds
   2. Evidence for Effectiveness
   3. Practical Advantages in the Mountain Environment
   4. Dosing Principles (Adults)
   5. When These Medications May Not Be Appropriate
   6. Bottom Line

MBC Has Narcotics Now

That about says everything that you need to know. They’ve surmounted their DEA difficulties and now have controlled substances. ALS providers can continue to administer controlled substances to our patients up to the time when the patient is transferred to the care of the clinic. Registration time is an intentional gray area. Use judgement.

Hands on in the Clinic

Though the clinic staff know that you shouldn’t be pushing medications for them, feel free to help them in other ways. Provided that you don’t have other duties to attend to, as medical director, I have no issues with you assisting with reductions or other care for patients that you have just delivered. This is at the discretion of the clinic provider, but can be good experience and a good way to build our relationship with the clinic providers.

Call For Orthopedic Questions!

I will be recording a podcast in a couple week about prehospital management of orthopedic injuries with Dr Chris Healy, one of our orthopedists at St Charles. He wants your questions! Please reply to this email with any that you might have about bones, breaks, sprains, splints, anything.

A couple of examples I have on tap:
Should we apply femur traction if it makes the patient more painful?
When would you want to actually take off a boot on the hill for your exam?

How to Call the Clinic

If you need to call the clinic on the phone rather than the radio:

Clinic Phone: 541-706-5901
Should ring the desk phone. Works Fri-Sun, otherwise routes to Bend South Urgent Care

Clinic Provider: 541-102-1663
Should call the clinic PA or MD directly. Requires them to have signed in appropriately, so may not be foolproof.

These numbers will be added to the reference page during the next update to the protocols.

Ibuprofen and Tylenol Pill Pack Education

I wanted to provide some background, particularly to our BLS patrollers who may have less experience administering these medications, on why Ibuprofen + Acetaminophen is a safe and effective pain control strategy for us to use.

We all have experience with these medications from treating our own fevers or headaches, but things always feel different when we’re administering them. I remember when a nurse first asked me in residency: “Can I get a dose of tylenol for this patient?”. My answer was something like, “I don’t know, can you? Is that ok?”.

Some background on the meds

Acetaminophen (APAP) and ibuprofen (an NSAID) act through different mechanisms:
• Acetaminophen reduces pain and fever through effect in the brain and has no anti-inflammatory effect.
• Ibuprofen inhibits inflammatory molecules, providing pain, fever, and anti-inflammatory effects.

Because they work at different sites, using them together produces synergistic pain relief; it’s better than either medication alone and, in many studies, better than combining a one of them with an oral opioid like oxycodone.

Evidence for Effectiveness

• Multiple studies and a large systematic review show superior pain control, fewer side effects, and higher patient satisfaction with APAP + NSAID combinations compared with either alone.
• This strategy is effective across a wide range of injury patterns, including acute traumatic and orthopedic pain.
• The approach is validated in austere and military settings, where APAP/NSAID combinations are used as first-line treatment immediately after injury.

Practical Advantages in the Mountain Environment

• Non-sedating: preserves mental status and mobility.
• Lightweight and low bulk: easy to carry.
• Opioid-sparing: often avoids the need for narcotics entirely.

Dosing Principles (Adults)

• Ibuprofen: 200–400 mg PO every 6 hours (analgesic ceiling ~400 mg per dose). We give a single dose of 600 mg PO to maximize anti-inflammatory effect as well.
• Acetaminophen: 60 mg/kg/day to a max of 4 grams, divided every 6 hours. We use a single dose of 1000 mg PO, which is the max reasonable dose for 6 hours.

When These Medications May Not Be Appropriate

If you combine the protocols for ibuprofen and tylenol, the three contraindications to know are:

1. Hypersensitivity: Duh. If they have a history of anaphylaxis or bad allergy to either med, avoid.
2. Ulcers or GI Bleeding: Ibuprofen is not good for these conditions. “Do you have any problems with ulcers or bleeding from your stomach?”
3. Pregnancy: Ibuprofen causes interesting problems in pregnancy that we should avoid. “Are you pregnant?” Given to excess in the first trimester, it can cause issues with fetal kidney development, which then causes issues with lung development and other downstream badness. Given in the third trimester, it can mess up fetal blood circulation. Don’t give ibuprofen to obviously pregnant women in the third trimester. The astute reader might wonder if we should avoid ibuprofen in women of childbearing age who could be pregnant. We don’t test for pregnancy in the ER before giving a single dose of an NSAID as a single dose is probably fine in the first trimester. So don’t sweat it.

Common misconceptions include the thought that alcoholics or those with liver failure or chronic kidney disease should studiously avoid these medications. Single doses will be fine as it’s sustained dosing that would do harm to these folks.

You may also encounter patients who tell you they can’t have medications, particularly ibuprofen, because they’re on a blood thinner or have had a gastric bypass operation. Neither of these patients will be grievously harmed by a single dose, but don’t administer if they bring up these objections.

Bottom Line

Particularly if given early after an orthopedic injury, ibuprofen plus acetaminophen is a safe, effective, and well-supported first-line pain strategy. When used at appropriate doses and with attention to contraindications, this combination provides strong analgesia, minimizes side effects, and aligns well with modern, opioid-sparing pain management principles in the austere environment.

Please let me know if this brings up other questions, if I’ve muddied the waters, or if you have other education you want me to address.

-PF