# Intranasal Narcan for BLS



## Jon (Feb 2, 2012)

Anyone giving Intranasal Narcan at the BLS level yet?

What do you think so far?

What is your protocol, and is there anything you'd change?


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## NYMedic828 (Feb 2, 2012)

Jon said:


> Anyone giving Intranasal Narcan at the BLS level yet?
> 
> What do you think so far?
> 
> What is your protocol, and is there anything you'd change?



I have heard talk of this for like a year now but haven't heard of it actually in place anywhere.

People told me there are supposedly auto-injectors out there now that they give to known abusers to have like an epi-pen.

My only worry would be that many don't even realize that it only takes 0.2mg of nalaxone to bring back many patients. "Overdosing" Narcan could result in dangerous withdrawal symptoms. But at the same time I guess if ALS is not available, or extended and the person has obvious respiratory failure than the risk of aspiration and a pissed off patient are better than the risk of respiratory arrest.

Not to knock anyone, but I know a lot of EMTs, intermediates and some medics that don't understand the potential some supposedly "harmless" drugs have and they just like the keep pumping the patient full. Slamming 2mg of Narcan down someones nose is a massive amount...

A set of 0.2 or 0.4mg auto injectors would be pretty nifty though. Standing orders of 0.2mg for respiratory depression/failure/arrest secondary to suspected opiate OD with a repeat of 0.2 would be pretty cool.


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## Veneficus (Feb 2, 2012)

As with anything, 

if adequete training, a functional system, and proper oversight are involved, I don't see it being a particularly bad idea. 

But good or bad and what needs addressed will be determined by actual practice.


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## Handsome Robb (Feb 2, 2012)

It could work well, but like NY pointed out it could turn bad as well. BVM + OPA or NPA works just fine...I could see standing orders for an arrest with opiod OD suspected but then you get into the argument of allowing basics to gain IV access because IM isn't going to cut it in that situation, not sure about IN but I don't see it working too well.


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## Tigger (Feb 2, 2012)

Boston EMS basics have been administering IN Narcan for sometime now. I am not sure what they're protocols are. I also know of a few police departments (Lynn and Quincy MA) that are also carrying prefilled IN Narcan setups. In Boston it's been very useful given the shortage of ALS trucks and proximity of hospitals.

Colorado EMT basics who have taken a state approved IV access class can also administer Narcan through both IN and IV routes. My IV instructor noted that the difference in onset between IN and IV are nearly identical, though he admitted that this was based only personal experience. Our protocol states to start with 0.4mg and then titrate to effect, up to 2mg.

Given that Narcan is packaged in prefilled syringes and prefilled IN setups, so I don't really see much of an issue with it when it comes to the providers making medication errors. So long as providers are receiving adequate education and aren't out trying to ruin people's highs by slamming the doses in, I think it's a fairly good idea. If the Narcan trial fails initially, then it's time to bring in ALS, or as NVRob said, NPA and bag them.


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## DrParasite (Feb 2, 2012)

My former medical director was 100% in favor of this.

unfortunately, the state isn't as progressive as he was.


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## the_negro_puppy (Feb 3, 2012)

I guess it could be useful is areas of high opioid abuse.

Having said that, we us IM Narcan and I have not used ti once in over 2 years running emergency calls.


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## Backwoods (Feb 3, 2012)

Id like to see it used in full arrests, but a pt w/ respiratory depression can be managed with a BVM & airway. The biggest thing is that there would need to be additional training.


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## medicdan (Feb 3, 2012)

I'm in the final stages of implementing a program to bring it to a BLS service... MA protocols make it fairly easy to implement beginning 3/1/12, so my service is taking it on with enthusiasm from our Med. Director and Hospital representative because of our service design. If anyone has specific questions, i'm happy to answer them...


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## Amberlamps916 (Feb 3, 2012)

Los Angeles county would never allow this.


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## Tigger (Feb 3, 2012)

Backwoods said:


> Id like to see it used in full arrests, but a pt w/ respiratory depression can be managed with a BVM & airway. The biggest thing is that there would need to be additional training.



Wouldn't it be better to remove the respiratory depression all together if possible. The BVM is a simple tool that many struggle to use effectively, if you can reverse respiratory depression,  wouldn't you want to? Ineffective bagging could be doing the patient some serious harm. 

I don't think pushing Narcan in every cardiac arrest is going to have useful effect, and as others here have mentioned it is not a harmless drug especially if the patient may need RSI in the near future.


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## downunderwunda (Feb 4, 2012)

ALL drugs have the potential for severe reactions. There are no such thing as safe drugs. I see no advantage in what is discussed. Oxygen will help & be more beneficial than naloxone. 

In 6 years I have had need to use it twice. Not as a primary treatment, but as an adjunct to oxygen therapy. Both of these were for prescription accidental overdoses. 

I don't know why you would consider lowering the standard for drug administration. 

Wouldn't it make more sense to up skill & increase education levels & abolish BLS as a skill level & make an EMT-I a minimum skill level to provide optimum treatment to all people, all the time?


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## Rev.IKON (Feb 4, 2012)

Addrobo87 said:


> Los Angeles county would never allow this.



i am surprised LA county even lets you look at a patient without fire being there.:rofl:


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## zmedic (Feb 4, 2012)

To those who say "just bag," I would say it depends on where you work. Where I do BLS shifts we are about 45minutes from the hospital, which is a long way to bag. Also I feel like you have a much higher chance of the patient vomiting from prolonged bagging, forcing air into the stomach, than if you use a little Narcan. 

To the idea of making everyone an EMT-I, it sounds great. But I have 2 issues. 

1. I know a lot of EMT-Bs who I wouldn't trust with an IV and I don't think have the smarts to give drugs. 

2. Is it fair if most people are paying for EMT classes out of their own pocket to make them pay for an EMT-I class, which will be longer and more expensive? You could argue that they would make more but I don't think our healthcare system is going to give all EMTs a raise right now.


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## Handsome Robb (Feb 4, 2012)

zmedic said:


> To those who say "just bag," I would say it depends on where you work. Where I do BLS shifts we are about 45minutes from the hospital, which is a long way to bag. Also I feel like you have a much higher chance of the patient vomiting from prolonged bagging, forcing air into the stomach, than if you use a little Narcan.
> 
> To the idea of making everyone an EMT-I, it sounds great. But I have 2 issues.
> 
> ...



So 2 things.

1. If you don't trust them starting an iv let alone with medications how is naloxone at the BLS level even feasible?

2. You gotta pay to play. We all complain about not being respected as a profession yet many refuse to further their own education in their chosen field.


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## systemet (Feb 4, 2012)

Why would you give narcan in arrest?  What are you trying to accomplish?


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## Hockey (Feb 4, 2012)

systemet said:


> Why would you give narcan in arrest?  What are you trying to accomplish?



If it was an opioid overdose...maybe?  I've pushed it before during an arrest...a few times.


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## Tigger (Feb 4, 2012)

NVRob said:


> So 2 things.
> 
> 1. If you don't trust them starting an iv let alone with medications how is naloxone at the BLS level even feasible?
> 
> 2. You gotta pay to play. We all complain about not being respected as a profession yet many refuse to further their own education in their chosen field.



There are places here giving it to MFR trained cops. If the junkie comes down stairs and says "he ODed," it seems to me that having the first person on scene reverse the respiratory depression instead of struggling to bag them one handed would be preferable.


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## Amberlamps916 (Feb 4, 2012)

Rev.IKON said:


> i am surprised LA county even lets you look at a patient without fire being there.:rofl:



In LA county, EMT's can look at a patient when it comes to dialysis, possibly even allowing use of a pillow


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## systemet (Feb 4, 2012)

Hockey said:


> If it was an opioid overdose...maybe?  I've pushed it before during an arrest...a few times.



Why?

What were you trying to accomplish?  These are asphyxial arrests caused by a prolonged period of blunted respiratory drive.  How is narcan going to fix this?


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## Bullets (Feb 4, 2012)

This
http://roguemedic.com/2012/01/what-about-nebulized-naloxone-narcan-part-i/

This
http://roguemedic.com/2012/01/what-about-nebulized-naloxone-narcan-part-ii/

AAAAND this
http://roguemedic.com/2012/01/comments-on-what-about-nebulized-naloxone-narcan/


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## downunderwunda (Feb 4, 2012)

zmedic said:


> To those who say "just bag," I would say it depends on where you work. Where I do BLS shifts we are about 45minutes from the hospital, which is a long way to bag. Also I feel like you have a much higher chance of the patient vomiting from prolonged bagging, forcing air into the stomach, than if you use a little Narcan.
> 
> To the idea of making everyone an EMT-I, it sounds great. But I have 2 issues.
> 
> ...



Firstly if you are 45 minutes from a hospital that's even more reason to be up skilled to provide all you patients with optimal care.

 As I have said in other threads, healthcare should not be run on a 'for profit' basis, but as a function of the state. This said, the education of officers should be provided by that organization. 

There will always be people we don't personally trust with drugs & IV's etc, however, if they stuff up internal reporting should weed them out. 

If people don't have the mental capacity to increase their skills, see ya. Pure & simple. Ems is a profession. We need 2 things for that to be seen. 1 is increased education & skills & 2 is total separation from fire. Only then can we truly be a profession.


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## zmedic (Feb 4, 2012)

downunderwunda said:


> Firstly if you are 45 minutes from a hospital that's even more reason to be up skilled to provide all you patients with optimal care.
> \



That's fine in the abstract. But this is a volunteer fire department, with about 10 EMTs, almost all of whom are doing something else full time. Recruiting and retaining members is a big issue. It's hard enough to get people to go through a 120 hour class, having everyone take the EMT B and a EMT I as well isn't going to happen, and I'm not sure it is worth it for a place where they run 30 calls a year. 

As to making everyone an EMT-I, I think there are plenty of people who I don't think should be doing drug calculations and starting IVs but who I would trust to stick tube up someone's nose and give 0.2mg of Narcan when their friend says they did heroin. 

Sure it would be great if everyone was an EMT-I, but I don't see it happening in the current funding situation.


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## Brandon O (Feb 4, 2012)

I am appreciative of the view, espoused by Rogue and others, that all the narcotic OD needs is bagging for his respiratory depression. However, realistically, in this world, ventilating with the BVM alone is not always easy, and if it comes down to the choice between sticking to the "principle of least medicine" and letting someone become hypoxic because you can't seem to reliably get the air in, it would be nice to have an effective out.

This would be somewhat similar to the opinion that giving BLS a King or Combitube is useful, not to replace intubation, but to replace unassisted bag-mask ventilation. The world is finally coming around to the facts that 1. One-person BVM is often quite difficult, and 2. We're not going to do mouth-to-mouth or mouth-to-mask so stop mentioning it. The consequences of this are numerous.


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## Veneficus (Feb 4, 2012)

Brandon Oto said:


> This would be somewhat similar to the opinion that giving BLS a King or Combitube is useful, not to replace intubation, but to replace unassisted bag-mask ventilation.



I cannot buy into this argument at all. 

Nobody ever died from not having a plastic tube in them. They die from not having a viable airway.

Somehow back in the days of wooden ships and iron men, when our options were manual maneuver, EOA, or intubation, we somehow managed to ventilate all but the most greviously injured trauma patients where the airway and surrounding structures were destroyed or burned.

These devices are not without their problems, and nobody benefits from from trying to make up for poor technique or lack of skill with a gadget. 



Brandon Oto said:


> The world is finally coming around to the facts that 1. One-person BVM is often quite difficult,.



What???

I have never had a problem and I have been around a while in some very high volume environments. 




Brandon Oto said:


> and 2. We're not going to do mouth-to-mouth or mouth-to-mask so stop mentioning it. The consequences of this are numerous.



This I agree with.


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## systemet (Feb 4, 2012)

Brandon Oto said:


> I am appreciative of the view, espoused by Rogue and others, that all the narcotic OD needs is bagging for his respiratory depression. However, realistically, in this world, ventilating with the BVM alone is not always easy, and if it comes down to the choice between sticking to the "principle of least medicine" and letting someone become hypoxic because you can't seem to reliably get the air in, it would be nice to have an effective out.



The trouble isn't so much giving a *small* amount of narcan to avoid having to ventilate a clear isolated narcotic OD.  It's hard to justify not doing that, but, in my opinion, the goal should be to avoid artificial ventilation, not to wake the patient to sign a cancellation.

It becomes more of an issue when the patient history is less clear / suspcious for coingestion, where narcan use might unmask more dangerous effects of other agents, and complicate the managment of the patient for several hours.  Especially in situations where the evidence for narcotic ingestion is weaker.

This often comes down to the volume of pure narcotic OD versus mixed ODs a system sees, which can vary greatly between different areas, and influences how likely any given patient is to be a pure narcotic OD.  It also depends on whether the medical community endorses, openly or otherwise, the practice of giving narcan and doing a cancellation (or, in some centers, scaring the patient away).  

I would argue, as well, that in the absence of aspiration or significant pre-existing lung disease, that it should be possible to oxygenate these patients adequately with small minute volumes.  The bigger danger in longer periods of BVM ventilation without an adunct is probably distending the stomach and risking regurgitation.  Ventilation, i.e. removal of CO2, may be more of an issue.

BLS does get stuck in the situation where reversing an agent may not be possible due to scope of practice, but managing the airway may be difficult because (i) there's no option for advanced airway, or (ii) once the patient's CO2 comes down from decent ventilation with an adjunct, now they're no longer as narcotised, and begin gagging.

However, giving BLS narcan also puts them in a situation where (i) they may unwittingly unmask a mixed overdose patient without having the tools to manage them, or (ii) they may precipitate acute withdrawal syndromes, including seizure activity, without the tools to manage it.

The trouble with a lot of the "EMT+" skills, is you exchange one set of problems for another, and it's not normally, in my opinion, done with a strong enough foundation of physiology, pharmacology, pathophysiology, etc.  [That's not intended as a slight to BLS, though I realise it may be perceived as such.].


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## Brandon O (Feb 4, 2012)

In general, I agree, systemet. For what it's worth, here are the requirements for use of BLS nasal narcan in our service:

If evidence of opiate use (patient or bystanders state use, visible paraphernalia, track marks, pinpoint pupils, AMS, respiratory depression, etc.)

and older than 14 years

with no recent seizures

and no trauma

and not in cardiac arrest

and no abnormal breath sounds

and no history of tramadol/Ultram use

and no history of therapeutic opiate use

and no nasal trauma, nasal obstruction, or epistaxis

then give 2mg nasal (1mg per nare) and call ALS. No repetition of dosage is allowed even with medical control permission.

The reason for some of these points are a bit of a mystery for me even now, but there you go -- obviously a very conservative protocol.

But I agree with almost everything you mentioned; that's a well-put summary of the different considerations.


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## Brandon O (Feb 4, 2012)

Veneficus said:


> I cannot buy into this argument at all.
> 
> Nobody ever died from not having a plastic tube in them. They die from not having a viable airway.
> 
> ...



The details of pro/con on blind airways is perhaps a topic for another day -- I'm not necessarily advocating their use by BLS, or indeed anybody. My point is rather than I'm more responsive to the argument that they can serve as a "better" or at least augmented BVM, rather than the argument that they can replace endotracheal intubation. In other words, in a way they may serve a larger need for the BLS provider than the ALS provider.




> What???
> 
> I have never had a problem and I have been around a while in some very high volume environments.



Well, applause. But many of us, from the lowliest EMT up through the boarded intensivist or emergency physician, regularly encounter difficulty with the pure BVM. Remember that it's one thing to be able to use the tool as a bridge to other interventions, such as intubation (or a bolus of narcan) -- but at the BLS level we have no second act. So what we're actually discussing is being able to take 100% of your opiate overdoses and bag them all the way from your arrival on scene until you turn over care at the ED (or possibly to ALS), consistently, reliably, and without adverse effects. That is a tall order. (If we expand the discussion to the BVM in general, it means taking every patient who needs help breathing and using nothing but the bag. The obese, the traumatic, the anatomically bizarre, the confined-space extrication, everyone.)



> This I agree with.



Truth be told I've begun to wonder if mouth-to-mask might have more value than we tend to grant it. It's just not on our radar normally, and perhaps it should be.


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## Tigger (Feb 4, 2012)

Veneficus said:


> What???
> 
> I have never had a problem and I have been around a while in some very high volume environments.



That's good, but it's not the case for many providers. I assume there is a reason that 2 person BVM use is now being promoted by the AHA, and I have read many times on this site that one needs to spend some serious time getting competent with the so called "anesthetists grip" before one can truly be good with using a BVM this way. 

I support Brandon's idea that so called blind airways may be in fact more useful for BLS providers given their lack of airway management options. Even with the greatest technique and an adequate number of hands, maintaining a mask to face seal is not always going to be easy, and we now have the ability to eliminate this weakness in the artificial respiration process.


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## Bullets (Feb 4, 2012)

I dont quite understand to two person BVM, so AHA is saying you would need 3 rescuers for a CPR, minimum. Unreasonable, BVM use is a skill like splinting, and requires practice, but it is not an impossible skill. As a Basic provider, its one of a handful of skills in our bag. I dont think proper BVM use is difficult

As far as IN Narcan, with proper education, pharmacology, i dont see why not, but i also dont see why


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## usalsfyre (Feb 4, 2012)

If you don't think proper BVM use is difficult, I have my doubts you've bagged all that many patients. 

Dr. Weingart stated the BVM was a bigger murder weapon than the laryngoscope on one of his podcast. I can't say I disagree.


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## Tigger (Feb 4, 2012)

Bullets said:


> I dont quite understand to two person BVM, so AHA is saying you would need 3 rescuers for a CPR, minimum. Unreasonable, BVM use is a skill like splinting, and requires practice, but it is not an impossible skill. As a Basic provider, its one of a handful of skills in our bag. I dont think proper BVM use is difficult
> 
> As far as IN Narcan, with proper education, pharmacology, i dont see why not, but i also dont see why



The person doing compressions can squeeze the bag twice and then return to compressions while the other provider concentrates on maintaining a good seal.


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## Handsome Robb (Feb 4, 2012)

systemet said:


> Why?
> 
> What were you trying to accomplish?  These are asphyxial arrests caused by a prolonged period of blunted respiratory drive.  How is narcan going to fix this?



http://www.ncbi.nlm.nih.gov/pubmed/19913979

small study.

My understanding is the CNS depression from opioids is not only limited to the respiratory system. 

That's my oversimplified, rudimentary understanding of it at least.


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## Brandon O (Feb 5, 2012)

Tigger said:


> That's good, but it's not the case for many providers. I assume there is a reason that 2 person BVM use is now being promoted by the AHA



If you dig my old EMT textbook off the shelf, and flip to the chapter on airway and respiratory management, you'll find something interesting: it clearly states that the order of preference is two-person BVM, mouth-to-mask, and lastly one-person BVM -- explicitly because maintaining a seal with one hand is simply not very effective. This is actually an old concept, but has been widely ignored, presumably because we're grossed out by getting that close to patients.

I find all this interesting.


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## Bullets (Feb 5, 2012)

Tigger said:


> The person doing compressions can squeeze the bag twice and then return to compressions while the other provider concentrates on maintaining a good seal.



No, shouldnt interrupt compressions, especially not for ventilation, which we still havent shown has any real benefit



usalsfyre said:


> If you don't think proper BVM use is difficult, I have my doubts you've bagged all that many patients.
> 
> Dr. Weingart stated the BVM was a bigger murder weapon than the laryngoscope on one of his podcast. I can't say I disagree.



i probably bag a patient once a week or 10 days. Lots of SNFs in my coverage area.


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## Amberlamps916 (Feb 5, 2012)

I've had numerous instructors express their frustrations with providers squeezing bags with way too much force....


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## Tigger (Feb 5, 2012)

Bullets said:


> No, shouldnt interrupt compressions, especially not for ventilation, which we still havent shown has any real benefit


It's not interrupting compressions. Compressions aren't being done while breaths are being delivered if an advanced airway is not in place. So long as the bag is angled the proper way while compressions are occurring and the seal is maintained at all times, it will take well less than 5 seconds to deliver the 2 breaths from the BVM following 30 compressions.

These are AHA guidelines.


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## Brandon O (Feb 5, 2012)

Although in most cases I wouldn't say anything to a provider who chose to give continuous compressions rather than stop to ventilate, in the case of the arrest s/p opiate overdose I think it would be a mistake to skimp on the breathing -- since hypoxia likely caused the problem to begin with.


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## Backwoods (Feb 5, 2012)

systemet said:


> Why would you give narcan in arrest?  What are you trying to accomplish?



My knowledge on this is quite limited, but I assumed that in the event of an arrest caused by prolonged respiratory depression/hypoxia that it may improve the chances of survival. I dont have the knowledge & training on that drug so please correct me if I am wrong.


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## usalsfyre (Feb 5, 2012)

Backwoods said:


> My knowledge on this is quite limited, but I assumed that in the event of an arrest caused by prolonged respiratory depression/hypoxia that it may improve the chances of survival. I dont have the knowledge & training on that drug so please correct me if I am wrong.



Oxygen reverses hypoxia. Not Narcan.

The only situation I can think of naloxone being useful is a pseudo-PEA secondary to opioid induced hypotension (i.e. never).


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## Brandon O (Feb 5, 2012)

usalsfyre said:


> Oxygen reverses hypoxia. Not Narcan.
> 
> The only situation I can think of naloxone being useful is a pseudo-PEA secondary to opioid induced hypotension (i.e. never).



Random anecdote, but I have seen more or less exactly this... the exact sequence wasn't clear, but it was a near-total PEA, textbook sinus on the monitor, nobody had any answers, until someone throw some naloxone down the IV on a whim and she started to come around. Odd one.


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## downunderwunda (Feb 5, 2012)

zmedic said:


> That's fine in the abstract. But this is a volunteer fire department, with about 10 EMTs, almost all of whom are doing something else full time. Recruiting and retaining members is a big issue. It's hard enough to get people to go through a 120 hour class, having everyone take the EMT B and a EMT I as well isn't going to happen, and I'm not sure it is worth it for a place where they run 30 calls a year.
> 
> As to making everyone an EMT-I, I think there are plenty of people who I don't think should be doing drug calculations and starting IVs but who I would trust to stick tube up someone's nose and give 0.2mg of Narcan when their friend says they did heroin.
> 
> Sure it would be great if everyone was an EMT-I, but I don't see it happening in the current funding situation.



You need to read all my posts in relation to this but I will make it easy. 

1. Fire is a profession. Ems is a profession. They should be separate. 

2. There are areas that taxpayers should fund. Healthcare, ems are part of that. They shod not be a for profit setup. 

3. There is no place for fully volunteer ems in today's world in first world countries. I wouldn't do that much study & time for no gain. As I said, ems is a profession. There is some justification for some billy services as a secondary adjunct to the professional service. 

4. With this said, you can run a retained service with a nominal retainer & payment for each call in quieter areas. There is then financial incentive to train & up skill. 

Sorry I'd I upset any volleys out there but it happens. For ems to progress it needs to be said. Mentalities need to change.


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## m0nster986 (Feb 6, 2012)

systemet said:


> Why would you give narcan in arrest?  What are you trying to accomplish?



He may have been taught the "Coma Cocktail.":glare:


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## Tigger (Feb 6, 2012)

downunderwunda said:


> 4. With this said, you can run a retained service with a nominal retainer & payment for each call in quieter areas. There is then financial incentive to train & up skill.



Could you shed some light on how this works? Obviously I'd love to have full-time ALS coverage for all, but how exactly do you provide this for a community that has 30 runs a year, surrounded by similar places? If you spread the units out enough to make the call volume cost effective you'd be looking at some pretty long scene times it seems?

It's getting better to be sure, I was recently transported by an agency that serves a town of less than 5000 (and are the biggest for many miles) that had ILS on board for most calls, but only one member was paid and the other two were volunteer. One of the volunteers was an intermediate, but I cannot imagine most volunteers are.


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## Handsome Robb (Feb 6, 2012)

Tigger said:


> It's getting better to be sure, I was recently transported by an agency that serves a town of less than 5000 (and are the biggest for many miles) that had ILS on board for most calls, but only one member was paid and the other two were volunteer. One of the volunteers was an intermediate, but I cannot imagine most volunteers are.



Eh the town I grew up in was less than 5000 and we had a dedicated ALS fire department. We did see a big influx of tourists in the summer though so that probably had something to do with it.


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## Tigger (Feb 6, 2012)

NVRob said:


> Eh the town I grew up in was less than 5000 and we had a dedicated ALS fire department. We did see a big influx of tourists in the summer though so that probably had something to do with it.



This town has a large ski area (hence the reason for my ride), but I was still surprised. The ski area also has medics that will ride in with their own equipment should the patient be serious. 

As a rule though most small towns in New England lack full time fire and EMS it seems. I am presently living in one of the more wealthy towns in MA yet we have POC BLS ambulance and fire. The cops have a maximum two cars on the road for the overnight, three at other times. The money is there, but the want is not which sucks. Medics can be 20 minutes away, which is too long half the time.


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## downunderwunda (Feb 6, 2012)

Tigger said:


> Could you shed some light on how this works? Obviously I'd love to have full-time ALS coverage for all, but how exactly do you provide this for a community that has 30 runs a year, surrounded by similar places? If you spread the units out enough to make the call volume cost effective you'd be looking at some pretty long scene times it seems?
> 
> It's getting better to be sure, I was recently transported by an agency that serves a town of less than 5000 (and are the biggest for many miles) that had ILS on board for most calls, but only one member was paid and the other two were volunteer. One of the volunteers was an intermediate, but I cannot imagine most volunteers are.



I love the way people only read what they want to see. Tigger this is point 2. 

2. There are areas that taxpayers should fund. Healthcare, ems are part of that. They shod not be a for profit setup.


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## Tigger (Feb 6, 2012)

downunderwunda said:


> I love the way people only read what they want to see. Tigger this is point 2.
> 
> 2. There are areas that taxpayers should fund. Healthcare, ems are part of that. They shod not be a for profit setup.



Relax, lay off the attitude.

All I wanted was a little bit more of an explanation of how this works.



> 4. With this said, you can run a retained service with a nominal retainer & payment for each call in quieter areas. There is then financial incentive to train & up skill.



It's not a system I am familiar with.


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## paradoqs (Feb 6, 2012)

Emt iv's can give iv and in narcan in my area and there are no contraindications. Indications are respiratory depression due to opiate od or unresponsive with unknown etiology. However, either of those chiefs are going to get an als response so its kind of pointless for us. The md's in my area are apparently not worried about any complications or side effects from narcan. I saw somewhere that they are giving it out to junkies for when their junky buddies od, so letting emt's give it doesnt seem like too bad of an idea. And get off the high horse about upping your skills. Emt's have a place in medicine and it isnt stopping ems from becoming a profession. Cna's are an integral part of hospital medicine and they arent keeping nurses from being recognized as health professionals. Being a cna is required for entry to a lot of nursing schools just like emt exp is and should be a prereq for medic school


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## downunderwunda (Feb 6, 2012)

I would have thought it self explanatory. 

Pay people to get their qualifications. Once qualified & registered they are paid a nominal allowance to be on call. Then when they are called they get paid for each call at a set rate for up to a certain period of time. 

This will then give an incentive for people to be involved & stay involved as well as maintaining their qualifications.


----------



## Handsome Robb (Feb 6, 2012)

downunderwunda said:


> I would have thought it self explanatory.
> 
> Pay people to get their qualifications. Once qualified & registered they are paid a nominal allowance to be on call. Then when they are called they get paid for each call at a set rate for up to a certain period of time.
> 
> This will then give an incentive for people to be involved & stay involved as well as maintaining their qualifications.



So where is all this money coming from, champ?


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## Medic Tim (Feb 6, 2012)

NVRob said:


> So where is all this money coming from, champ?



He has already answered this question.


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## Handsome Robb (Feb 6, 2012)

Medic Tim said:


> He has already answered this question.



You can say taxes as an answer to pretty much every funding problem. 

It's not a plausible answer. In a perfect world, yea sounds great. In the current economy, not the case.


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## ffemt8978 (Feb 6, 2012)

NVRob said:


> You can say taxes as an answer to pretty much every funding problem.
> 
> It's not a plausible answer. In a perfect world, yea sounds great. In the current economy, not the case.



And what happens when the taxpayers reject an increase in their taxes, despite being educated on the benefit it could bring?


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## Tigger (Feb 7, 2012)

downunderwunda said:


> I would have thought it self explanatory.
> 
> Pay people to get their qualifications. Once qualified & registered they are paid a nominal allowance to be on call. Then when they are called they get paid for each call at a set rate for up to a certain period of time.
> 
> This will then give an incentive for people to be involved & stay involved as well as maintaining their qualifications.



Ah, a retainer system is just like paid on call. Just wanted to be sure. But to place someone on call you have to pay them a fair amount to make it worth their while to alter their life. No alcohol use, etc, while on call. Considering that there are many, many towns in this country that average an EMS call every two weeks, that's a lot of time on call. I can't imagine it's a desirable assignment, and to combat boredom one would need to hire more crews, making it more expensive.

For me, it comes down to getting what you pay for. If you live in the middle of nowhere and pay tiny taxes, then you shouldn't expect excellent public services. If you want better service, move to where the tax base exists to support it.


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## Tigger (Feb 7, 2012)

NVRob said:


> You can say taxes as an answer to pretty much every funding problem.
> 
> It's not a plausible answer. In a perfect world, yea sounds great. In the current economy, not the case.



Many states could raise the their taxes despite the economy, and I'm not sure it would be the worst thing to ever happen. It might just create jobs, but I don't want to get into that argument here.

What is more troubling is the states that demand a popular vote on tax hikes, like Colorado. There is simply no way to generate new funding, because residents flat out refuse to ever pay more taxes if given the choice unless it can be shown that they will receive a direct benefit. Much of the tax increases will only assist the smaller portions of the population, those living in poorer areas (both rural and urban) are simply outnumbered by those who are receiving more than adequate state and city services.


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## downunderwunda (Feb 7, 2012)

ffemt8978 said:


> And what happens when the taxpayers reject an increase in their taxes, despite being educated on the benefit it could bring?



Interestingly enough there are many ambulance services worldwide who operate on this basis. The mentality of pay for everything is what holds people back. As I have stated previously, some things should be controlled by government to ensure quality & availability of supply. Healthcare, education, law enforcement gas & electricity supply. Essentials of life. They can still be run to attain profit but those profits ate used to provide better services. 

The more people use a service, the more viable it becomes. 

I encourage you to think outside square. Think outside what you consider "normal" & open your eyes & mind to other possibilities.


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## ffemt8978 (Feb 7, 2012)

downunderwunda said:


> I encourage you to think outside square. Think outside what you consider "normal" & open your eyes & mind to other possibilities.


We have...and our voters (i.e. the people that pay for the taxes that support us) have rejected it on more than one occasion.


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## downunderwunda (Feb 7, 2012)

I ask why is that? Answer: because it is not explained properly to them in a language they understand. Put simply a nominal increase in taxes that most people wouldn't notice, would fund all services. 

Many people pay for health insurance, Australians pay a 2.75% tax for free healthcare, they can also elect to have private, more extensive healthcare, of they are pensioners, free healthcare, prescriptions for $5.40 each. 

Gee I think if it is explained properly, I a language people can understand, then the vast majority would be accepting of it. 

The simple truth is, in my humble opinion, that the US governments, at all levels, has convinced the vast majority that the systems in place should be there as a profit making venture. That governments should be entitled to take & waste money. They justify this through declaring war on terror, then carrying it on for over 10 years, incurring trillions, yes trillions of dollars debt. Spending billions every year on drug detection with no real success. The conspiracy theorists might blame the CIA got that one. 

When was the last time one of these politicians, a so called elected representative of the people, had to really think about how much a loaf of bread cost? Or how much gas costs? Or maybe how much an ambulance costs & the subsequent hospital bills cost? 

Let me answer. Never. Do they want a change? No because while they keep the majority in the dark, they keep pocketing all their money, allowances etc. 

Maybe they need to live on struggle street like most of us do. Not in their ivory towers barking at us what's best for us, but learning to listen to the majority of voters, then they might learn. 

If you don't believe we are told what to be scared of consider this from recent history. 

From the end of WWII, we were told to be fearful of the commies, be scared if reds under the bed, so we had the Korean conflict, a police action, this continued through to Vietnam in the 60's & 70's as well as the early 80's. The came the end of the cold war. That didn't last long though. The early 90's had operation desert storm. We were told how scared we had to be of saddam & his weapons of mass destruction. 

We then had tragedy in 2001 in new York , 2002 in Bali, & again in 2005 in London. So now we have to have a war on terror. 

How about instead if all of these distractions & having to go to war, we look at what we can do to benefit our own people. Spend their tax dollars more wisely & offer the services they need, without looking for profit.


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## ffemt8978 (Feb 7, 2012)

downunderwunda said:


> I ask why is that? Answer: because it is not explained properly to them in a language they understand. Put simply a nominal increase in taxes that most people wouldn't notice, would fund all services.


 That's an easy assumption to make, and you're wrong.  It's been explained to them in a language they understood, but they chose to not support it.  It is not an end sum game of "do this because you're wrong if you don't" (at least not in this country.)  

Also, when you are dealing with a tax base of 1500 people, how much of a non-noticable tax increase would actually effectively fund a full time EMS service?


downunderwunda said:


> Many people pay for health insurance, Australians pay a 2.75% tax for free healthcare, they can also elect to have private, more extensive healthcare, of they are pensioners, free healthcare, prescriptions for $5.40 each.


Actually, the majority of people around here don't have health insurance.  Your 2.75% tax increase would almost double our current sales tax rate of 7%, taking sales taxes as an example.  



downunderwunda said:


> Gee I think if it is explained properly, I a language people can understand, then the vast majority would be accepting of it.


Then you don't understand how America works.  People are free to make their own choices, even if you believe it is the wrong one.  No amount of explaining it will change everyone's mind.

As to the rest or your post, I'm not even going to bother addressing it.


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## systemet (Feb 8, 2012)

ffemt8978 said:


> Also, when you are dealing with a tax base of 1500 people, how much of a non-noticable tax increase would actually effectively fund a full time EMS service?



This is a point that is often missed in the discussion when considering US systems (and is also relevant in some parts of Canada).  If EMS is a municipally funded entity, there's a great disparity in how much resources different communities have to direct towards it.

In many other countries EMS is a federally funded public service.  This changes the variables a lot.



> Actually, the majority of people around here don't have health insurance.  Your 2.75% tax increase would almost double our current sales tax rate of 7%, taking sales taxes as an example.



Well, technically that would be increasing it by less than 50%.  However, this whole discussion is making a bunch of assumptions.  

US healthcare is (I think) the most expensive per capita in the world, and about the only system in an industrialised country that doesn't universally insure.  If (and this one big, if, because there's a lot of vested interests opposing this), it was restructured towards a European system, it might cost a lot lot less.  

If the Australians pay a 2.5% sales tax towards healthcare (I think this might actual be a payroll/income tax, perhaps someone can clarify), I'm sure the cost of insuring the currently uninsured would be less than the cost of reproducing the entire Australian healthcare system. 

Also, in a global context, a 7.5% sales tax is pretty low.  For example:

Canada - has provincial and federal sales tax, varies by province from 5-15%
Australia - 10%
Sweden - 25% (also the employer pays a 31% payroll tax!)
UK - 20%  (a little over 10 years ago this was "only" 15%)
New Zealand - 15%
Norway 25%
South Africa - 14%
France - ~ 20%
Germany - 19%
Mexico - 16%

[Most countries have a lower rate on transportation costs, or on supermarket food items, children's clothes, etc.]

Part what's being missed in the fiscal responsibility debate in the states, is the choice not to tax is a choice not to collect revenue.  Tax cuts have the same result as spending.  Also, it's not like the US budget isn't actually quite large.  If money was redistributed from defense spending, it might easily cover healthcare reform.



> Then you don't understand how America works.  People are free to make their own choices, even if you believe it is the wrong one.  No amount of explaining it will change everyone's mind.



Yeah, because the US is so different from any other democratic nation on the planet?  The US is intrinsically different and "more free" than Canada, the UK, New Zealand, Australia, France, Germany, Italy, Spain, Portugal, Sweden, Norway etc. Those are all police states like Syria or North Korea where dissent is brutally crushed by state police?

People are just as free in many other industrialised countries, with just as many democratic rights.  Freedom is not restricted to the borders of the US.  Have you considered that you may not understand how it works in other countries?



> As to the rest or your post, I'm not even going to bother addressing it.



I think you just did


----------



## downunderwunda (Feb 25, 2012)

Well said. But I would like to add that if ambulance services are properly funded, educated & trained then they can, with the appropriate protocol's, reduce the burden on hospitals. 

With appropriate resources there is no reason why people cannot be left at home, with protection for the officers, to see a GP later. 

Why take a known post octal epileptic to hospital when it is a semi regular occurrence? The most appropriate course of action is to leave them in the care of a responsible person, provided there are no unusual circumstances, with a referral to their own Dr. 

Same with a diabetic hypo in a known diabetic, or asthmatic. 

Here is one to make you think, gastroenteritis. Contagious, & one of the worst patients to take to any hospital. Provide antiemetics, fluids, stay at home. 

Now add up the cost savings to the health system from these patients & redirect it to ambulance training, equipment & education. 

Then we might be seen as a true profession, not a bunch of cowboys.


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## jwk (Feb 25, 2012)

Veneficus said:


> What???
> 
> I have *never* had a problem and I have been around a while in some very high volume environments.



Nobody, and I mean NOBODY, has NEVER had a problem with a BVM.  You may think you're ventilating EVERY patient adequately, but I can tell you that is simply not in the realm of possibility.


----------



## jwk (Feb 25, 2012)

downunderwunda said:


> Well said. But I would like to add that if ambulance services are properly funded, educated & trained then they can, with the appropriate protocol's, reduce the burden on hospitals.
> 
> With appropriate resources there is no reason why people cannot be left at home, with protection for the officers, to see a GP later.
> 
> ...



The Aussies do a lot of things that aren't done in the rest of the world.  Penthrane (MOF) inhalers for example.  Correct me if I'm wrong, but essentially nobody else uses those.

I'm guessing Australia also doesn't have the medico-legal climate that prevails in the US.  Taking your gastroenteritis example - in the US you can't pop them with ondansetron, leave a liter of LR running, and tell them to see their doc tomorrow.  There is far too much potential liability.  Nor can they start at IV and then hang around for an hour to D/C it.  That takes them out of service far too long.  That's simply not why they are there.  

EMS, at least in the US, is not supposed to be a primary care medical provider.  They aren't physicians, PAs or NPs - they aren't trained to that level of differential diagnosis.  I'm curious - can you give me a differential diagnosis for nausea, vomiting, and belly pain?  Gastroenteritis is the a very tiny tip of the iceberg.  

The *E* is for EMERGENCY - it's not RMS with the R standing for routine.


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## Brandon O (Feb 25, 2012)

jwk said:


> The *E* is for EMERGENCY - it's not RMS with the R standing for routine.



Still in the early stages of development is my idea-baby, a proud institution of Urgent Medical Services -- UMS for short. Staffed with UMTs ("umpties") and UMT-Ps ("ummm, teepees?"), we deal with, ummm, the other stuff.

Coming soon to a region near you. Just dial 119.


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## docmoods (Mar 21, 2012)

DrParasite said:


> My former medical director was 100% in favor of this.
> 
> unfortunately, the state isn't as progressive as he was.



Yea ditto...


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## Scott33 (Mar 22, 2012)

Suffolk County, NY, are currently looking into trailing IN Narcan for basics.

http://www.suffolkremsco.com/clientuploads/Downloads/BLSNarcanPilotProgramn312.pdf


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## Av8or007 (Apr 28, 2013)

Some people need to watch Weingart's "laryngoscope as a murder weapon" lecture. It not only goes into the physiology of intubation, but it also goes into the "art and science" of the BVM and how to use it properly without killing the patient in the process.


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## wanderingmedic (Apr 28, 2013)

Brandon Oto said:


> Still in the early stages of development is my idea-baby, a proud institution of Urgent Medical Services -- UMS for short. Staffed with UMTs ("umpties") and UMT-Ps ("ummm, teepees?"), we deal with, ummm, the other stuff.
> 
> Coming soon to a region near you. Just dial 119.



:rofl:
this made my day. I think that is how I will intro myself to the next call I get from one of our frequent flyers.


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## StopNgo1000 (Jun 15, 2013)

Does anyone have any issues with IN narcan ?

the downfall of it?

Of course i see positives...

extending the training to BLS providers, having a different route of administration with it comes to pts that overdose from needles, cutting down the risk of bloodborne pathogens, etc


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## Wheel (Jun 15, 2013)

StopNgo1000 said:


> Does anyone have any issues with IN narcan ?
> 
> the downfall of it?
> 
> ...



No offense, but did you read the thread? Downsides were discussed in good depth. One is that you run the risk of undereducated providers giving too much and causing acute withdrawal symptoms. Honestly, with the current educational climate this is a risk with ALS providers as well.


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## StopNgo1000 (Jun 15, 2013)

My apologies , I read through it fast sorry . Thank you


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## Wheel (Jun 15, 2013)

StopNgo1000 said:


> My apologies , I read through it fast sorry . Thank you



Not a problem, sorry if I was a bit snippy


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## TheLocalMedic (Jun 18, 2013)

I'd rather have a BLS crew put a patient into withdrawls than rely on them to effectively ventilate and apneic overdose.  Sorry, but I've seen the volly departments here in action and I can't in good conscience say that they do very well at ventilating people.  It's a skill you have to practice to be any good at, and they just don't get to do it often enough to do it well.


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## Trashtruck (Jun 18, 2013)

Or bag them too hard, blow their stomach up, and have them vomit and aspirate before you arrive.


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## hogdweeb (Jun 19, 2013)

service I run with ahs it on board for Basics. I have not gone through the course, but ive heard from the one person I know of who has administered it luckily took the edge off and made the patient "functional" without killing his high.


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## Bullets (Jun 20, 2013)

TheLocalMedic said:


> I'd rather have a BLS crew put a patient into withdrawls than rely on them to effectively ventilate and apneic overdose.  Sorry, but I've seen the volly departments here in action and I can't in good conscience say that they do very well at ventilating people.  It's a skill you have to practice to be any good at, and they just don't get to do it often enough to do it well.



As if poor ventilation and BVM use is province of volunteers or BLS. 

Im no volunteer apologist, if they dont work then they need to be replaced, but BVM use and proper ventilation is a skill no provider gets a ton of practice on and it is a perishable skill. Think how many IV starts youve done in your career, think how many patients youve bagged. I bet you have many more IV starts


There is no need for BLS to carry this. Regardless of the level of education BVM is the better care choice in most cases. As long as the patient is able to maintain a respiratory drive there is little use for Narcan. If a patient is just unconscious and breathing well, then its not an overdose. I see allowing BLS administer IN Narcan as a recipe for lots of providers giving it like Oxygen...."if we have it, why not use it"


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## Carlos Danger (Jun 20, 2013)

Hmmm.....EMT's and narcan.....where do I start?

I would not be appropriate for an EMT to be responsible for choosing whether to use diltiazem vs. amiodarone vs. adenosine to treat a symptomatic tachycardia. Or choosing between propofol and ketamine to facilitate a painful procedure. 

However, there are some drugs where the indications are clear and the benefit:risk ratio low. Aspirin for chest pain in a patient with a cardiac history. An epi auto-injector for a kid with a known peanut allergy who is blowing up like a balloon and wheezing like Fat Albert climbing stairs in the school cafeteria. Glucagon auto-injector for the unresponsive diabetic and the glucometer reads "LO". IN versed or a valium suppository for someone with a seizure history in status epilepticus. These are all cases where it's usually pretty clear whether the drugs are indicated, where they probably wouldn't do much harm even if they were given inappropriately, and where having them vs. not having them could potentially be the difference between life and death.

And I think narcan for a suspected opioid OD is along these lines, too. Maybe not quite as clear cut as some of those examples, but pretty close.

Narcan is generally a safe and effective drug. Yes, it comes with risks. But an unsecured airway and a full stomach in a patient who has essentially put himself under general anesthesia is pretty risky, too. Especially when the EMT's (or paramedics) on scene may not be as skilled with the BVM as they should be.

There seems to be a lot of anti-narcan rhetoric on the EMS interwebs lately, and I'm not sure where it comes from. I know some of it is bravado ("I-dont-need-no-stinkin-narcan-I-can-intubate", or it's close variation, "narcan is for nurses - paramedics use plastic!"), but I think a lot of it is just overestimation of the potential hazards of narcan combined with an under-appreciation for the dangers of BVM'ing a full-stomach, narcotized, potentially acidotic patient.


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## milehimedic (Jun 21, 2013)

Tigger said:


> Boston EMS basics have been administering IN Narcan for sometime now. I am not sure what they're protocols are. I also know of a few police departments (Lynn and Quincy MA) that are also carrying prefilled IN Narcan setups. In Boston it's been very useful given the shortage of ALS trucks and proximity of hospitals.
> 
> Colorado EMT basics who have taken a state approved IV access class can also administer Narcan through both IN and IV routes. My IV instructor noted that the difference in onset between IN and IV are nearly identical, though he admitted that this was based only personal experience. Our protocol states to start with 0.4mg and then titrate to effect, up to 2mg.
> 
> Given that Narcan is packaged in prefilled syringes and prefilled IN setups, so I don't really see much of an issue with it when it comes to the providers making medication errors. So long as providers are receiving adequate education and aren't out trying to ruin people's highs by slamming the doses in, I think it's a fairly good idea. If the Narcan trial fails initially, then it's time to bring in ALS, or as NVRob said, NPA and bag them.


Colorado even goes one step further. If you are a civilian, you can now obtain prescription narcan after a 1-hour class and administer it in the field. Drug policy here is extremely progressive.

http://www.leg.state.co.us/clics/cl...5A469A6087257AEE00570637?Open&file=014_01.pdf


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## Tigger (Jun 21, 2013)

milehimedic said:


> Colorado even goes one step further. If you are a civilian, you can now obtain prescription narcan after a 1-hour class and administer it in the field. Drug policy here is extremely progressive.
> 
> http://www.leg.state.co.us/clics/cl...5A469A6087257AEE00570637?Open&file=014_01.pdf



The Massachusetts Department of Public Health has been giving prefilled IN Naloxone for several years to the family and friends of opiate drug users. It's been very successful.


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## Carlos Danger (Jun 21, 2013)

Tigger said:


> The Massachusetts Department of Public Health has been giving prefilled IN Naloxone for several years to the family and friends of opiate drug users. *It's been very successful*.



You mean they aren't dropping dead left and right from opiate withdrawal?


----------



## DrParasite (Jun 21, 2013)

milehimedic said:


> Colorado even goes one step further. If you are a civilian, you can now obtain prescription narcan after a 1-hour class and administer it in the field. Drug policy here is extremely progressive.
> 
> http://www.leg.state.co.us/clics/cl...5A469A6087257AEE00570637?Open&file=014_01.pdf


Intersting.... giving narcan to civilians who recieve a 1 hour class makes drug policy progressive, but if anyone mentions EMTs giving it, then" omg, we can't trust them with this dangerous medication!!!!"


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## milehimedic (Jun 21, 2013)

DrParasite said:


> Intersting.... giving narcan to civilians who recieve a 1 hour class makes drug policy progressive, but if anyone mentions EMTs giving it, then" omg, we can't trust them with this dangerous medication!!!!"



Don't shoot up the messenger :rofl:

It is different when a person is on-duty and acting in an official capacity than when a civilian is medicating a close friend or family member with a known history. 

That said, as an online protocol with all necessary contraindications in districts where ALS could be a while arriving on scene, it can make sense. However, how many districts with a heavy opiate abuse population don't have ALS less than 10 minutes out?


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## Jon (Jul 4, 2013)

milehimedic said:


> Don't shoot up the messenger :rofl:
> 
> It is different when a person is on-duty and acting in an official capacity than when a civilian is medicating a close friend or family member with a known history...



Not really. But bigger thing... Is narcan the only solution to the hypoventilation problem? Or can a BLS provider fix the problem for as long as needed with an airway and a BVM?


----------



## Carlos Danger (Jul 4, 2013)

Jon said:


> Not really. But bigger thing... Is narcan the only solution to the hypoventilation problem? O*r can a BLS provider fix the problem for as long as needed with an airway and a BVM?*



Not most EMT's I've known.


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## NomadicMedic (Jul 4, 2013)

Halothane said:


> Not most EMT's I've known.



Agreed. Most EMTs with a BVM resemble a monkey with a football. 

Not really their fault, but poor education and lack of any opportunity to practice on real people


----------



## Carlos Danger (Jul 4, 2013)

DEmedic said:


> Agreed. Most EMTs with a BVM resemble a monkey with a football.
> 
> Not really their fault, but poor education and lack of any opportunity to practice on real people



:rofl: It's funny cuz it's true. 

And most paramedics I've seen were no more proficient at it than their BLS partners. I'll freely admit that I wasn't as good at it as I should have been, even as (especially as) someone who did a lot of RSI's. 

It isn't easy to properly ventilate a patient who isn't breathing adequately, but also probably isn't completely relaxed. Some patients (thick beards, stiff necks or jaws, large tongue, sleep apnea, etc) are nearly impossible to effectively BVM even in good circumstances, then add in moving and transferring. Not to mention the fact that these patients aren't NPO, and likely aren't protecting their airway properly.

Small doses of IM or IN narcan is the way to go if a patient isn't breathing and protecting their airway, IMO.


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## NomadicMedic (Jul 5, 2013)

I agree, many medics suck at the BVM, simply from lack of practice. I'm not great, but better than most, just because I've done it a bunch. And I'm not afraid to enlist help to get a good seal and have someone else squeeze the bag for me. 

Squeezing 10 breaths into a plastic head in the intubation check if action does not make you skilled at bagging. 

In my paramedic program, we did an exercise called "bag a buddy" where you had to ventilate a partner with a BVM for an extended period of time. Uncomfortable and difficult, to say the least. Although after a few sessions, I could get pretty comfortable. It's one of those skills that takes some real practice.


----------



## Craig Alan Evans (Jul 5, 2013)

Robb said:


> It could work well, but like NY pointed out it could turn bad as well. BVM + OPA or NPA works just fine...I could see standing orders for an arrest with opiod OD suspected but then you get into the argument of allowing basics to gain IV access because IM isn't going to cut it in that situation, not sure about IN but I don't see it working too well.



It is much safer to train BLS providers to give Narcan than it is to have them pump the patients stomach up with air, cause them to vomit, and aspirate. I believe IN Narcan is light years above of BVM+OPA for BLS providers.


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## NomadicMedic (Jul 5, 2013)

Just had a respiratory arrest that fully illustrated the lack of EMT skill in bagging. It became a teaching experience while I was getting ready to RSI the patient. Having ETCO2 as a visual guide was a help.

Also, narcan would have done nothing in this case, except needlessly delay BVM use.


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## Milla3P (Jul 5, 2013)

I'm not going to lie; I haven't read all 90 posts in this thread so I don't know if this has come up. BUT:

My state has had nasal narcan for BLS for a couple of years. The same amount of time ALS has had both IN narcan and Versed. 

I've done both IN and IM with both narcan and versed and feel that IM is superior in all aspects. 

IM is a relatively rapid and predictable administration route. 

I feel that IN is not. There is patience required. Most inexperienced BLS providers get a little too amped up when somebody isn't breathing. Add on top of that that they get to give *GASP* a drug (zomg!!!!!) and the Provider usually presses a hair on the fast side and doesn't properly atomize the drug. The drug doesn't properly stick to the mucosa and starts dripping down the airway and is counter productive. 

Like I've said I've given narcan both of the possible BLS routes and prefer IM. Hell I think IM is better than IV when I think that 0.4 will make them come to completely. I hate waking opioid addicts.


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## Tigger (Jul 5, 2013)

For what it's worth the majority of the issues associate with EMTs giving IN Naloxone can be attribute to training issues. If they're giving it to fast or when it's not indicated, that's not a medication safety issue. If you're people can't be trusted to give it properly, then don't allow them to. But that doesn't mean that there aren't many out there working for services that do have the proper programs in place to ensure successful use of the medication.


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## the_negro_puppy (Jul 7, 2013)

Milla3P said:


> I'm not going to lie; I haven't read all 90 posts in this thread so I don't know if this has come up. BUT:
> 
> My state has had nasal narcan for BLS for a couple of years. The same amount of time ALS has had both IN narcan and Versed.
> 
> ...



Our protocols are 1.6mg IM only. (Intensive Care can give iv) :huh:


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## Trashtruck (Jul 8, 2013)

Milla3P said:


> Hell I think IM is better than IV when I think that 0.4 will make them come to completely. I hate waking opioid addicts.



Ummm...0.4mg IM???

If we're giving Narcan IM or IN, it's 2mg right off the bat.


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## rwik123 (Jul 8, 2013)

Trashtruck said:


> Ummm...0.4mg IM???
> 
> If we're giving Narcan IM or IN, it's 2mg right off the bat.



umm no it's not. Have fun slamming 2mg's of narcan. My protocols call for titrating to effect in 0.4 increments.


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## Trashtruck (Jul 8, 2013)

I can assure you, rwik123, it is.

If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.

If I were giving Narcan, IV, it would be given in 0.4mg increments.

I see that you're an EMT-B. Do you give IM/IN Narcan in 0.4mg increments?


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## TransportJockey (Jul 8, 2013)

Trashtruck said:


> I can assure you, rwik123, it is.
> 
> If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.
> 
> ...



Our basics give it 0.4 starting for IM and 2mg for IN. But most services don't do IN anymore since their basics can just do IM. Besides if I don't have to wake a junkie up then I'm happy.


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## rwik123 (Jul 8, 2013)

Trashtruck said:


> I can assure you, rwik123, it is.
> 
> If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.
> 
> ...



Well you may not, but we do. EMT-I. Haven't updated my profile in a while.


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## Milla3P (Jul 9, 2013)

Trashtruck said:


> I can assure you, rwik123, it is.
> 
> If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.



Nightmare. The last thing I want to do is wake these jamokes up. I just want them to breathe independently (professionally, not personally). 

So yes. 0.4 IM. If I'm REALLY concerned and they're small they get 0.2 IV. Narcan is for respiratory issues related to opioid overdose. Not "fixing" them.


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## Bullets (Mar 17, 2014)

So the county immediately south of us has approved IN Narcan for all police officers....

This is due to a more than doubling of fatal heroin overdoses in from 2012 to 2013 to a whopping 112. But heres the even better part, if a police officer is also an EMT, they can not carry or administer because DOH doesnt allow it. 

I still think this is a bad idea, mostly because i find giving cops a 1 hour class and then carrying a temperature sensitive drug in the trunk of their car for .01% of the population absolutely ridiculous. I know our cops trash their medical bags and AEDs and leave them in the cars overnight even when its below freezing so i can see this ending poorly when its been below zero for days and they try to administer this


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## Jmo371 (Mar 17, 2014)

NYS has approved it but our medical director in central NYS just needs to put the protocol in place....i cannot see a reason why the pre-filled narcan should not be at the BLS level....


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## mycrofft (Mar 17, 2014)

Talking to an ER nurse last month. Narcan causing abrupt withdrawal in a pregnant addict can likely cause fetal death, premature birth.


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