San Diego, California - Whether rendering first aid at a car crash in Carlsbad, California, or stabilizing a wounded Marine in Karbala, Iraq, pain management from point-of-injury to the hospital, is a priority for both civilian and military emergency medical professionals alike.

But due to a nationwide shortage of some pain killing narcotics, it is a priority that has become increasingly difficult to meet throughout San Diego County.

The shortage is spurring emergency medical professionals to seek alternate drugs and protocols for pain management.

This is why Dr. Kristi Koenig, Medical Director of Emergency Medical Services for the County of San Diego Health & Human Services Agency, enlisted the U.S. Navy to share its unique insights into pain control alternatives.

Cmdr. Brendon Drew, emergency medicine physician and chairman of the Naval Medical Center San Diego (NMCSD) Emergency Medicine Department, was one of several guest speakers invited to the County of San Diego Base Station Physicians' meeting at the Sharp Spectrum Auditorium, Feb. 20.

"A part of the reason we're having this discussion is now we're short on meds, now we're short on morphine, and we're asking ourselves, 'what are some other options?'" said Drew, as he addressed the dimly lit roomful of emergency medical personnel from throughout San Diego County. Drew primarily discussed U.S. Navy pain management protocols and guidelines for the use of ketamine in a prehospital setting, which is prior to a patient's arrival at a hospital.

Ketamine is an anesthetic that can be administered nasally and has lower abuse potential than opioids, but it is not commonly used by the civilian medical community in prehospital settings throughout San Diego County.

It is, however, used by Navy medical facilities, such as NMCSD and Naval Hospital Camp Pendleton (NHCP), both located in San Diego County, and by combat medics in the battlefield.

Drew traded thoughts with the audience and discussed evidence-based practices codified in Navy-wide guidelines. From how to properly administer a "fentanyl lollipop" to the challenges of injecting an IV while inside a banking helicopter, he shared best practices gleaned from his experiences during eight overseas deployments to places like Iraq and Afghanistan.

According to Koenig, the Base Station Physicians' Committee may adopt the Navy's guidelines for ketamine as they develop the prehospital ketamine use protocols for San Diego County, which are planned for submission to the California State EMS Authority for review.

If approved, the newly incorporated protocols could help the county mitigate effects of the current shortages - a welcome result of the longstanding partnership between Navy Medicine and the County.

"The County of San Diego (COSD) enjoys an excellent relationship with Navy Medicine. COSD Emergency Medical Services (EMS) and Navy Medicine have worked collaboratively on multiple initiatives of common interest. The County appreciates that a large portion of our population are active duty military, their dependents, and veterans. In support of the Live Well San Diego, we work together to keep our community safe and healthy for daily routine EMS emergencies as well as for less frequent public health emergencies and disasters," said Koenig via email.

The Navy and COSD EMS support each other on several fronts through mutual aid and training to deliver care and ensure integrated responses to natural and manmade disasters like wildfires and multi-vehicle crashes.

Much of the collaboration takes place through regular meetings and venues like last year's COSD EMS-approved Scripps Day of Trauma conference and the San Diego County Emergency Care Summit, where Navy and civilian medical professionals from throughout the county exchanged expertise leading to improvements in medical response capabilities.

Cmdr. Ben Walrath, director for Navy Medicine West EMS, provides medical direction for fire and emergency services aboard Navy and Marine Corps bases and installations, and Navy Bureau of Medicine & Surgery EMS agencies throughout the U.S. West Coast and Asia-Pacific Region.

A public health expert, Walrath is also Navy Medicine West's primary liaison to COSD EMS officials. Navy Medicine West is the U.S. Navy's healthcare system serving the Western Pacific and more than 675,000 beneficiaries throughout California, Washington, Hawaii, Guam, South Korea, Japan and Diego Garcia.

According to Walrath, several improvements in emergency response capabilities can be attributed the integration of systems and standardization among the civilian and military EMS providers throughout San Diego County.

For instance, tracking patients and documenting their care as they transition from point-of-injury to the hospital is a challenge COSD EMS and Navy Medicine tackled through integration and information sharing. "San Diego County invested in a prehospital data collection system and has shared access to the software with our agencies to ensure we have the ability to track and document the prehospital care provided," said Walrath via email, adding that the seamless visibility helps the Navy Medicine enterprise ensure patients receive the highest standards of care.

According to Walrath, Koenig has been a major catalyst for collaboration on domestic and international fronts. "Dr. Koenig is an expert in many things, perhaps most notably is disaster medicine. She has offered her expertise both locally and to our providers overseas to help us improve our readiness to respond to major disasters and (help) others prepare as well."

Dr. Koenig and her staff have supported U.S. Navy international medical education exchanges by sharing their expertise and network of prehospital professionals across the globe.

Emergency medicine in disaster response is no new concept to the Navy, which does so on a global scale. More than 500 Sailors from Navy Medicine West are currently aboard Military Sealift Command hospital ship USNS Mercy (T-AH 19), in support of Pacific Partnership 2018 - the largest annual multilateral humanitarian assistance and disaster relief preparedness mission throughout the Indo-Pacific Region.

In partnership with Canada, the United Kingdom, Australia, France, South Korea, Singapore and Japan, the Sailors aboard the Mercy are collaborating from shore to shore, as the 894-foot-long former oil tanker makes its way to countries like Indonesia, Sri Lanka, Malaysia and Vietnam, to help strengthen national capacities and preparedness for disasters and emergency response.

From San Diego to Singapore, the Navy Medicine enterprise continues to expand and strengthen partnerships.