Andy Anderson is a former Firefighter & First Responder for Suqualena VFD, Paramedic with Metro Ambulance, former part-time SWAT Medic with DPS backing up MBN & MHP. He currently works as a part-time Deputy with Lauderdale County Sheriff’s Department’s SWAT Team, ER Physician at a Level I Trauma Center, Medical Director for Central Mississippi EMS District, and Medical Director for Hinds CC Paramedic program. He also teaches firearms classes at Boondocks Firearms Training Academy.
Andy AndersonBy Andy Anderson
Advanced Cardiac Life Support (ACLS) has evolved significantly over the years, and in the 1990s, one of the most talked-about changes was the introduction of escalating doses of epinephrine.
Instead of giving the standard 1 mg of epinephrine every 3 to 5 minutes, the protocol called for progressively larger doses: 1 mg, then 3 mg, then 5 mg, with 7 mg as the maximum dose.
When the new protocol rolled out, we stocked our drug boxes with multi-dose vials of epi. I was working with Gray one day when we were dispatched to a 911 call for a cardiac arrest. Upon arrival, we found a lifeless patient with family members performing CPR.
Gray and I took over, initiating defibrillation, intubation, and IV access.
Then came the new dosing protocol.
* 1 mg of epi—no change.
* 3 mg of epi—still nothing.
* 5 mg of epi—and suddenly, a pulse!
The success was short-lived. Before we could even load the patient onto the stretcher, they went back into cardiac arrest. We gave another 5 mg dose, and again, the patient regained a pulse.
Gray, recognizing the patient’s apparent reliance on epinephrine, decided to start an epinephrine infusion. At the time, I was an Intermediate and in Paramedic school and had never seen an epi drip used in the field.
By the time we arrived at the ER, the patient still had a pulse. It was a small victory, but one that didn’t lead to long-term survival.
Reflecting on that time, I believe the escalating dosing protocol led to more patients being delivered to the ER with a pulse, but studies later showed it didn’t improve survival to discharge or neurological outcomes. As a result, the protocol was discontinued in the next iteration of ACLS guidelines.
Moments like these underscore how EMS is constantly evolving.
Every seasoned paramedic has stories of techniques that were cutting-edge at the time but were later refined or abandoned. Writing them down preserves those moments, reminding us of how much the profession has grown and how much we’ve learned along the way.
