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Thread Title: IV Ativan administration
Created On Wed Feb 03, 2010 11:38 AM
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nightmicu
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Wed Feb 03, 2010 11:38 AM

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Greetings,

Ativan has been in our box since last summer but I have only needed to administer it twice, both times this month. Our drugs are in locked boxes and cannot be handled unless they are being used on a call, which makes it impossible to familiarize ones self with packaging and individual characteristics of each item in the box unless you are on a call or afterward.

My first encounter with Ativan was not the best, I was given an order for 1 mg and had some difficulty trying to figure out the injector system that the vial screws into. I was able to administer the drug but not without a slight delay, which was very frustrating (the patient was perfectly stable, A/Ox4).

When I reached the ER, I spoke with the receiving RN hoping for a teachable moment and she told me that she hates the injector (blue plunger device, not sure of the manufacturer's name) and always draws from the vial with a syringe and needle. On Sunday I had a patient who had reportedly been seizing for an extended period of time and administered 2 mg of Ativan per protocol and per MD's order.

This time, I drew the drug up into a 1 cc syringe and administered without difficulty. The vial contains 2 mg of the drug in 1 cc but the markings on the vial itself go to 2 cc. Again, I asked the receiving RN about this and she said "oh, that's to get the air out."

Is anyone out there carrying lorazepam in this form - with a long vial and injector device? If so, how do you prefer to administer the drug, and how does one expel the 1 cc of air without inadvertently wasting any of the drug itself? From what I gathered from the two RNs in our ER, I am not the only one who finds it frustrating.

Thanks!

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PARAMEDICMIKE
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Wed Feb 03, 2010 3:23 PM

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You must work in New Jersey. I think that's part of your problem.

So you drew up the medication into a syringe and gave it that way. It worked for you, right? I'm not sure I see the problem here. You adapted and succeeded. What's more, I think you're worried too much about what two nurses think. My guess is that they were simply annoyed or didn't want to bother answering your questions than they were frustrated with drawing up medications.

-be safe

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 -be safe


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"There is an incessant influx of novelty into the world, and yet we tolerate incredible dullness."
-Thoreau

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nightmicu
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Wed Feb 03, 2010 3:32 PM

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Actually, I am in Virginia. I tend to write too much and can make things more complicated than they need to be, so I apologize if my initial post was confusing.

Essentially, I am trying to learn how to use this injector properly without needing to use a syringe and needle combination. I wish I knew the proper name for the device used to inject the medication, the best I can do is try to explain it. It is blue, shaped like a T, with a locking mechanism to secure the vial on one end and a plunger on the other.

Again, the vial contains 2 mg of the drug in 1 mL of fluid, however the markings on the vial are up to 2 mL. As I understand it, you need to expel exactly 1 cc of air prior to actually pushing the drug. Does anyone know how to accomplish this without the possibility of wasting any of the actual medication?

Until recently our morphine was supplied in the same fashion, luckily they have switched to a regular vial.

Thanks..

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Zorfox
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Wed Feb 03, 2010 6:14 PM

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I have used syringe holders similar to that. It has been awhile but from my recollection it is pretty simple. The “T” part is the lock which you twist a quarter turn to drop the base down. Then you insert the end of the vial with the screw into the base and slide the top into the “U’ at the top. Twist the base back and screw the plunger into the threaded vial.

If that’s the one you’re talking about I feel you frustration. Forgetting to twist the base makes the vial impossible to insert. My suggestion would be to not toss the empty vial and holder next time. Familiarize yourself afterwards. I see no reason not to save the empty vial if the medication has been properly disposed of.

I must have misunderstood about the air problem BUT, as far as expelling the air… hold the vial with opening up and withdraw to allow the medication to settle in the bottom of the vial. Lorazepam is thick and takes time to settle. Then depress the plunger until medication begins to flow. Don’t forget to lick the excess of your fingers of course! lol


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nightmicu
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Wed Feb 03, 2010 6:39 PM

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Aye, I almost took a picture of this on Sunday. Okay, the vial that contains the drug is supplied in a clear tube holder, it's very narrow and about 3" long. It appears to have a needle attached to it (covered by a yellow protector), a Leur Lock connection under that, and a typical rubber needle port under that. Confusing? Tell me about it...

If the patient end indeed has all three methods of delivery, there must be some way to break the seal (rubber needle port) in order to push the drug. The T shaped component is just tossed in the drug box by the pharmacy and is not specific to lorazepam.

I feel somewhat stupid going to a physician or the pharmacy with this question, but in reality it's a breakdown in our training when these changes were made to our protocols. Still, if anyone has any idea what I am talking about, please share...

Thanks

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NSMEDIC
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Wed Feb 03, 2010 6:44 PM

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There must be a time you can get a look at the box for manufacturer info, and the box should come with directions? (that you can stuff in your pocket for future reference).

But I really have no idea what you're talking about though... we don't carry Ativan (unfortunately) and we don't lock anything up like that. Off-duty and spare narcotics are the only things that are locked up. Nor do we ask for orders.

Tell your MD to take an Ativan and loosen up!

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nightmicu
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Wed Feb 03, 2010 6:50 PM

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Originally posted by: NSMEDIC
There must be a time you can get a look at the box for manufacturer info, and the box should come with directions? (that you can stuff in your pocket for future reference).

But I really have no idea what you're talking about though... we don't carry Ativan (unfortunately) and we don't lock anything up like that. Off-duty and spare narcotics are the only things that are locked up. Nor do we ask for orders.

Tell your MD to take an Ativan and loosen up!


Yeah, unfortunately it's a regional thing.. every single drug we carry, right down to the ASA and D50, are in boxes that cannot be closed once they are opened (locked open, actually). And there are several drugs, including Ativan, that are simply put in sealed baggies with nothing more than the writing on the vial itself -- no box, no instructions. Nor are there instructions of any kind on the T shaped injector I have been talking about.

So, guess I have to bite the bullet and look stupid in order to provide better patient care in the future. I try to find 1 cc syringes with needles (just easier for a lot of drugs) but they're hard to come by in our supply closet.

Private company that doesn't care about training their employees and a rural EMS system, it's sad...

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nightmicu
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Wed Feb 03, 2010 6:54 PM

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Originally posted by: PARAMEDICMIKE
You must work in New Jersey. I think that's part of your problem.



Ohh, did you say that because of my nickname? I indeed lived in NJ, the land of the MICU's, for about 12 years before moving to VA. Went to an EMS school in Philly and never actually ran in Jersey, but liked "MICU." I have actually seen it on license plates of squads down here, guess I started a trend (on my license plate).

-Ben

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PARAMEDICMIKE
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Wed Feb 03, 2010 10:26 PM

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It is the MICU reference and your paramedic training in Phithadelphia that led me to think New Jersey. You went to Star Tech? That's in the Northeast.

In all the years I lived in Virginia I never heard a reference to a MICU.

-be safe

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*************************************
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"There is an incessant influx of novelty into the world, and yet we tolerate incredible dullness."
-Thoreau

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nightmicu
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Wed Feb 03, 2010 10:37 PM

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Originally posted by: PARAMEDICMIKE
It is the MICU reference and your paramedic training in Phithadelphia that led me to think New Jersey. You went to Star Tech? That's in the Northeast.

In all the years I lived in Virginia I never heard a reference to a MICU.

-be safe


Indeed I did attend Star Tech, Ted Goldman was the director at the time and Russ Engle was my Paramedic instructor, both have moved on to other places. I completed my ride time in Levitown, Bensalem, Medic 11 (South Philly), and Medic 1 (China Town).

I can't remember if it was Henrico or Hanover here in VA, but one of those two agencies has "MICU" on their license plates.

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ESPARKS
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Wed Feb 03, 2010 11:16 PM

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We have the same administration device for our narcs. The blue "T" handle is 2" wide and the plunger is about 3". They are used with glass vials prefilled with the meds. We call the versa-jets. Don't know if that the trade name or not. Ours are needless system. I'll take a closer look at one tomorrow and see if there's a name on them. I've seen them in catalogs like boundtree & moore medical supply.
Ed

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nightmicu
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Wed Feb 03, 2010 11:20 PM

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Originally posted by: ESPARKS
We have the same administration device for our narcs. The blue "T" handle is 2" wide and the plunger is about 3". They are used with glass vials prefilled with the meds. We call the versa-jets. Don't know if that the trade name or not. Ours are needless system. I'll take a closer look at one tomorrow and see if there's a name on them. I've seen them in catalogs like boundtree & moore medical supply.
Ed


That sounds about right, Ed! If you could provide some instruction on these that would be fantastic.

Thanks!

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roblanious
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Wed Feb 03, 2010 11:40 PM

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We use a lot of prefilled syringes for narcs and benzos and have been for some time. Here is a video on the carpaject.carpaject.

Look down below at this site and you will find instructions for the tubex syringe, another device for injecting the same prefilled syringe. We have these tubexes and carpaject devices all over the place. Nurses for some reason are not sure how to use them and go the extra steps of drawing up the med.
You will find on some of the prefilled syringes, that if after you hook it up, and you meet resistance and cannot inject your drug, push down on the top needle part (obviously not the needle itself unless you have the cap on it. At the other end of the injector site, there may be a small needle that has to penetrate into the ampule itself, so that is why you may have to push down on it. Usually, you won't have to do this.

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Zorfox
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Thu Feb 04, 2010 1:11 AM

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Sorry I thought you were asking how to use the holder. Rob is correct to press the leur tip down and puncture the seal. It is amazing how many people fumble with these for that reason. Rob, you are SO right about nurses not using the holders. I don't understand why they choose to draw it up either, but to each is own I suppose.

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roblanious
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Thu Feb 04, 2010 5:58 AM

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Nurses are generally more educated than we are. Not more smarter.

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G.Arthur Keough (1909-1989) Educator

Edited: Thu Feb 04, 2010 at 5:58 AM by roblanious

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nightmicu
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Rob, that is it exactly! Thank you so much for the link, very valuable information.

I am fine with using a syringe and needle as long as one is easily accessible, it makes it easier to draw up smaller amounts of the drug without messing with the Tubex. But the next time I need to administer the full dose of Ativan, I will certainly use the system as intended!

Now, that still leaves the question of the mysterious 1 cc of what one nurse told me is air in the vial. How does one expel this without wasting any of the drug? Also, even though the markings go to 2 cc, the entire vial was empty after I administered 1 cc... very odd.

Thanks!!

-Ben

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foxtrotdelta
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Thu Feb 04, 2010 8:04 AM

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I had a similar problem the first time I had to give Diazepam out of one. I had no carpajet injector so I ended up using Midazolam instead which came in your run-of-the-mill vial. I didn't want to fuss with disassembling the tube.

Since then I bummed a carpajet injector off a hospital and I keep it in my gear.

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VanHelsing
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Thu Feb 04, 2010 10:33 AM

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we just have the usual glass vials of lorazepam, so can't help with the actual question however...

I'd suggest asking whoever is in charge of your drug supply to open up a case and let you play around with all the drugs, its the best way to learn, and i'm sure the other folk you work with are having the same issues. Have a workshop/ CME type thing for the whole base.

Or go to the pharmacist, rather look silly infront of them, then wait until you have a room full of anxious family members wondering why you look unsure and are not administering the drug to stop their fitting loved one. looking like you know exctly what you are doing is part of winning over your patients trust!!

Where in Virginia do you work ? I'll be visiting front royal in March.

VH

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nightmicu
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Thu Feb 04, 2010 1:35 PM

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Originally posted by: foxtrotdelta

Since then I bummed a carpajet injector off a hospital and I keep it in my gear.


Now that I think of it, I am not even sure there was one in that last drug box. I had decided that the next time I pushed Ativan I'd use a syringe so I did not really search for it, but normally it's right on top and rather visible.

How right you are, VH! I plan on poking around in the box with the pharmacist next time, they seem pretty approachable and I am sure I will not be the first one to ask questions like this.

As for the whole thing concerning nurses, I am happy to say that EMS and our hospital staff get along VERY well with few exceptions. We serve a rural area and primarily transport to a small community hospital, I am friends with several of our nurses and have not had a single negative encounter in the five years I have worked in the area.

Thanks for your help!

Edited: Mon Feb 08, 2010 at 11:02 AM by nightmicu

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roblanious
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Originally posted by: nightmicu
Rob, that is it exactly! Thank you so much for the link, very valuable information.

That is what we are here for, other than to argue with people we don't know personally.

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I am fine with using a syringe and needle as long as one is easily accessible, it makes it easier to draw up smaller amounts of the drug without messing with the Tubex. But the next time I need to administer the full dose of Ativan, I will certainly use the system as intended!

You will find these laying about most healthcare facilities as they are laying about the trucks and stations here around Pa. Since RNs don't like using them, they will be happy to use them. Look for both kinds of injectors, the Carpaject and Tubex as the prefilled syringes. We used to carry them on our person until they were laying about everywhere.

Quote
Now, that still leaves the question of the mysterious 1 cc of what one nurse told me is air in the vial. How does one expel this without wasting any of the drug? Also, even though the markings go to 2 cc, the entire vial was empty after I administered 1 cc... very odd.

Nurses look at these similar to the the Insulin syringes. When drawing up insulin syringes, the common practice is to draw up an extra unit, to make up for that unit of air that you cannot see below the needle. Then before injecting the med, you eject the air as you normally do, and this is usually about 1 unit. You really don't have to do that with these prefilled syringes. Just do as you normally do when drawing up and injecting a standard medication. Simply remove the cap, point the needle up and push out the air until you just get the medicine coming out, just as you were taught. Don't worry about what the nurses are telling you. Just draw it and inject it as you normally would. If the syringe says there is 1 ml in there, then there is 1 ml, regardless of the syringe size. The rest is just air. Simple as that. Just remember as Zorfox stated above, if you cannot expell the air because of great resistance, push down on the top needle part as some of them require a plunger to pierce a vial. Here is a detailed picture of the syringe with plunger.. I hope this helps.

BTW, though I admit nurses are more educated than paramedics, I am a big advocate of Paramedic training and education being equivelant or exceeding that of nurses. That is a whole other ARGUMENT.




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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
G.Arthur Keough (1909-1989) Educator

Edited: Fri Feb 05, 2010 at 1:15 AM by roblanious

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PARAMEDICMIKE
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Fri Feb 05, 2010 11:01 PM

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I've been thinking about this for a little bit.

How can one be a medic for going on five years and not have any idea how to draw meds in the fashion being discussed here? How can one be a medic for going on five years and have never seen tubexes, carpujects and related drug packaging? Yes. Pharmaceutical packaging varies. But to have never seen it?

These are serious questions. I'm finding this just a little mind boggling. I don't believe this has anything to do with locked drug boxes with access only when administering meds. This has got to go deeper.

I'm not calling out the OP on anything. I'm sure he's not the only one in this particular situation.

Anyone want to try and explain this?

-be safe

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"There is an incessant influx of novelty into the world, and yet we tolerate incredible dullness."
-Thoreau

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nightmicu
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Fri Feb 05, 2010 11:14 PM

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Originally posted by: PARAMEDICMIKE
I've been thinking about this for a little bit.

How can one be a medic for going on five years and not have any idea how to draw meds in the fashion being discussed here? How can one be a medic for going on five years and have never seen tubexes, carpujects and related drug packaging? Yes. Pharmaceutical packaging varies. But to have never seen it?

These are serious questions. I'm finding this just a little mind boggling. I don't believe this has anything to do with locked drug boxes with access only when administering meds. This has got to go deeper.

I'm not calling out the OP on anything. I'm sure he's not the only one in this particular situation.

Anyone want to try and explain this?

-be safe


If I had a penny for every Medic I have met who claims to know absolutely everything I would be a very wealthy man. I did very well throughout my Paramedic program and have not had any other problems with medication administration.

This is a new drug in our box and I was never specifically taught how to administer drugs packaged in this way. I was not sure so I asked my peers. If you would like to attack me or question my abilities, go ahead.. but it is the Paramedic that learns from their mistakes and asks questions that saves more lives.

Hopefully these forums prove to be a place to find support and education and not a place where we judge one another.

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atelectasis
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nightmicu... I dont think Mike was being offensive, but more questioning education in general. I too looked at this thread the other day, and honestly thought about it... knew exactly what you were talking about... and was kinda baffled/mind boggled that it took so long for anybody to even give the name. Where I come from, tubex and carpujects are common, especially w/ the benzos. It is a common packaging, and should def. be understood. Just dont take offense to it like you have... this is a site for education and that is what I believe Mike was looking for... why do we have paramedics that don't know what this stuff is? Certainly these are common ways of packaging...even worse... if you are supposed to be carrying it packaged in this fashion... its not only your responsibility to know your equipment, but every person above you, to make sure you have the tools available and the knowledge base, to get the job done, with the tools they have provided. Good luck to you nightmicu, and you will see... this page really is a great learning tool. Use it, and continue to use it, and I promise... one day... it will help you out!

-Tim

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PARAMEDICMIKE
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Sat Feb 06, 2010 12:33 AM

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Oversensitive much? Or just poor reading comprehension? Perhaps you missed the part where I mentioned I wasn't specifically calling you out because I'm sure others are in the same situation you're in.

Your track record in paramedic school, five plus years ago, is not relevant. Especially when one considers where you did your paramedic training.

If you think I was attacking you I refer you back to my opening paragraph in this post. If I wanted to attack you I could come up with much more scathing rhetoric than what you've read from me in this thread. Ask anyone here. They'll tell you.

As has been mentioned, the system you described, demonstrated in the videos Rob posted and confirmed by you as what you're talking about, is extremely common. So common, in fact, that that is what caused me to wonder just how a provider with five years in the field had never encountered such a system before.

If you want to think I was attacking you, well, that's on you. But I suggest you lighten up, work on your reading comprehension and grow some thicker skin.

Also, nowhere did I suggest I knew it all. If I was a know it all do you think I would've bothered to ask the question?

-be safe

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-Thoreau

Edited: Sat Feb 06, 2010 at 12:39 AM by PARAMEDICMIKE

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nightmicu
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Sat Feb 06, 2010 10:22 AM

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Mike, how are you not calling me out when you specifically mention every detail that I have posted in this thread? You may as well have said "how is it that this guy has been a Paramedic for so long and not know this?" Perhaps next time you should try to be more general, something more along the lines of "clearly we need to focus more on how some medications are packaged and administered so there is no confusion."

Also, insulting the school I attended, my reading comprehension, and calling me overly sensitive certainly does not help anyone. I actually used to be a moderator for America Online and would have been ejected very quickly for putting a poster in a position where they felt unwelcome or singled out, my mission was to facilitate positive discussion and welcome new visitors. You certainly succeeded in making me not want to post another thread on these message boards, thank you for that.

To those of you who were courteous and professional, thank you for your help. My question was answered and I will not have any further difficulties with this type of packaging.

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PARAMEDICMIKE
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Sat Feb 06, 2010 12:44 PM

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Originally posted by: nightmicu
Mike, how are you not calling me out when you specifically mention every detail that I have posted in this thread? You may as well have said "how is it that this guy has been a Paramedic for so long and not know this?" Perhaps next time you should try to be more general, something more along the lines of "clearly we need to focus more on how some medications are packaged and administered so there is no confusion."


As I previously mentioned, this isn't about you specifically. But since you brought it up, I'll ask.

How is it that you've been a medic for so long and don't know this?

To take that one step further, how can anyone who's been a medic for as long as you have not know this?

As I mentioned, it kind of boggles my mind. How is it that in your years of working as a paramedic you don't know how to do this? What kind of packaging is used for your narcs? Do you just not, as a practice, administer pain meds to patients? The system you describe is used as narcotic packaging in every system across five states that I've encountered. It's been used in every hospital to which I've transported patients in at least seven states. This isn't anything new.

Every system is different. The opportunity here for everyone to learn was missed because you felt threatened by someone questioning you. That you don't like how a serious question was presented and take personally the manner in which it was intended, when it was clearly mentioned you weren't being called out, is more a reflection on you than it is anything else.

Reading through the thread again I found this little gem,

Quote
Until recently our morphine was supplied in the same fashion, luckily they have switched to a regular vial.


Can you please explain, again, your lack of familiarization with this form of packaging? Did you just not give patient's analgesia because you didn't know how to make it work?

Quote
Also, insulting the school I attended, my reading comprehension, and calling me overly sensitive certainly does not help anyone.


I know more about your school than you think. Your attendance at that particular institution doesn't say much. That you managed to pass your paramedic exam indicates that you were determined to succeed despite the school. Or are you still upset you paid way too much for your time there?

Coincidentally, I know for a fact that the services you mentioned having done ride time at for your paramedic program use medications packaged in the exact manner you described here having never seen before. They used that same packaging five to six years ago when you would have been doing your ride time. How did you make it through paramedic school without administering medications using this type of administration method?

Quote
I actually used to be a moderator for America Online and would have been ejected very quickly for putting a poster in a position where they felt unwelcome or singled out,


Why did you feel unwelcome and singled out? Because I questioned you? An attempt to understand the motivation behind a question suddenly becomes an issue of singling out an individual? You came here and asked a question. That opens you up to question in return. If you don't want to be questioned then don't ask questions.

Quote
my mission was to facilitate positive discussion


And positive discussion only takes place when no one else asks questions in a discussion? Because you didn't like being questioned suddenly makes this a negative discussion? I'll go back to, oversensitive much?

You said you wanted to facilitate positive discussion. There are two ways to handle that. You can take seriously the honest questions that are asked in an attempt to clarify the background of the discussion or you can pretend to be offended. You have contradicted yourself in this very discussion. Don't get mad when someone is looking for clarification. It just makes you look more suspicious.

-be safe


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"There is an incessant influx of novelty into the world, and yet we tolerate incredible dullness."
-Thoreau

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ussenterprise2
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Well, I have to say, despite my 26 years as an RN have never come across this type of packaging either, although we don't carry benzos on our ambulance because we are just a BLS service.

I did come across a similar situation recently involving a rather complicated set up for mixing a med. I read the package insert a few times so that I would know what to do when the patient came in, and in the end, realised it was just a fancy system for mixing and delivering the IV med.

Geez, Rob, I didn't realize how complicated things were in the real world, what with lock-boxes, tamper-proof vials etc. I guess live a very sheltered life up here.....

Mo

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Edited: Sat Feb 06, 2010 at 1:25 PM by ussenterprise2

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foxtrotdelta
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Sat Feb 06, 2010 9:17 PM

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Maybe I'm naive, but I find it fairly believable that there are places and systems that don't regularly use carpuject systems. If I were in charge of purchasing medications for my agency, I would not purchase them on the grounds that it involves two pieces to properly use. That's another piece which can break, be misplaced or in my case, stolen.

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roblanious
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Sun Feb 07, 2010 5:53 PM

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Originally posted by: foxtrotdelta
Maybe I'm naive, but I find it fairly believable that there are places and systems that don't regularly use carpuject systems. If I were in charge of purchasing medications for my agency, I would not purchase them on the grounds that it involves two pieces to properly use. That's another piece which can break, be misplaced or in my case, stolen.

Generally to give an IV medication, you almost always need two pieces of equipment. The medication container and the syringe. Here, the medication is already in the syringe, but you need a device to inject it.

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How can one be a medic for going on five years and not have any idea how to draw meds in the fashion being discussed here? How can one be a medic for going on five years and have never seen tubexes, carpujects and related drug packaging? Yes. Pharmaceutical packaging varies. But to have never seen it?

I was wondering that too but gave the OP the benefit of the doubt that it may have been a non-progressive system that remained using different containers. I too wonder how one can go through medic class without learning this system, but with the poor quality of medic schools in the US, I am not surprised. I meet medics who don't know a lot of what they should. How many still are not taught adequate 12 lead interpretation?
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Well, I have to say, despite my 26 years as an RN have never come across this type of packaging either, although we don't carry benzos on our ambulance because we are just a BLS service.

Then what do you use up there Mo, for administering your benzos?
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I did come across a similar situation recently involving a rather complicated set up for mixing a med. I read the package insert a few times so that I would know what to do when the patient came in, and in the end, realised it was just a fancy system for mixing and delivering the IV med.

Similar situation here. Two nurses I work with handed me an antibiotic that requires a similar, and yet common mixing system that these two nurses were not familiar with. I had to ask, "you never seen this mixing format before?" They both shook their head, as I showed them how to do it.
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Geez, Rob, I didn't realize how complicated things were in the real world, what with lock-boxes, tamper-proof vials etc. I guess live a very sheltered life up here.....

This is in part because of these being controlled substances. I can tell you though that most ambulances in Western Pa. have unlocked lock boxes in their trucks. The lockboxes are for ambulance licensure. Having to fumble with another key or combination is a pain so most leave them unlocked but for the lock on the drug box itself.

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Zorfox
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Sun Feb 07, 2010 8:50 PM

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Personally I have never worked for a department that used carpujects. So I to can understand the confusion among other Paramedics. My introduction was working in the ED. If not for that I may not have known how to use them either. I wasn't taught how to use them in school as well. Of course that was quite some time ago.

Is the confusion over the difference between pre-filled syringes and “tubex” vials? Maybe so. I have used vials, ampules and pre-filled in the field. The tubexs he speaks of are a little different only in they have an innocuous seal that needs to be ruptured and a non attached delivery device used. I do think it is ridiculous the training department does not explain how to utilize equipment and supplies used.

I do understand Mike's train of thought. I would think it would be taught in Paramedic programs today. But obviously not. As far as benzos I have always used vials or ampules before.

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