# The Combative Opiate Patient



## Elk Oil (Jul 11, 2011)

I've done some searching and can't find any discussion on this, so I thought I'd throw it out there and get some of your experiences.

We all know that generally-accepted practices surrounding the use of narcan for opiate overdoses.  We've heard the prevailing philosophy that the patient (may/will) awaken and become violent.  In fact, I've worked with some EMTs who refused to administer it in the field because of their fear of what the newly-conscious patient would be like.

My question is this:
How much are these fears rooted in reality and how much in lore? 

I've seen loads of heroin overdoses treated with narcan over the years and have never experienced a violent patient.  All my patients have been confused and lethargic.  Some even apologetic.

Thanks for sharing your thoughts and experiences.


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## mycrofft (Jul 11, 2011)

*Use protocols not "generally accepted practices".*

I have not seen someone come up swinging from Narcan, but my experience with that is limited. I've seen diabetics come up swinging after glucose a couple times.


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## STXmedic (Jul 11, 2011)

Ive had several come up swinging. However, they are usually not solely opiate ODs (of course, we don't know this at the time...). All the ones I've had come up swinging are typically speedballing. Meth or coke. Brown is a popular one around here too (No, not you, Brown  )


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## Shishkabob (Jul 11, 2011)

I try not to slam Narcan.  I push it slowly to return normal respiration / maybe wake them slowly.    Groggy patient = a losing patient in a fight.  



I've had more trouble with postictal patients....


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## STXmedic (Jul 11, 2011)

Linuss said:


> I've had more trouble with postictal patients....



Seconded!


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## TransportJockey (Jul 11, 2011)

Linuss said:


> I've had more trouble with postictal patients....



This. And I think I pushed Narcan my first time 3 days after starting working as a basic. I usually will only give enough to bring their respirations back to normalish. I don't bother trying to wake up the OD most times


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## usalsfyre (Jul 11, 2011)

Maybe my experience is atypical, but I can count on one hand the number of times I've had a patient truly depressed enough for naloxene. And I could have gotten by with suction an NPA and a BVM.

I typically don't push the stuff in the field. Not because I'm scared of a violent awakening, just because there's no need.


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## STXmedic (Jul 11, 2011)

usalsfyre said:


> Maybe my experience is atypical, but I can count on one hand the number of times I've had a patient truly depressed enough for naloxene. And I could have gotten by with suction an NPA and a BVM.
> 
> I typically don't push the stuff in the field. Not because I'm scared of a violent awakening, just because there's no need.



If our city transported every pt that was found as an unconscious opiate OD, our hospitals would be over-crowded and on diversion all day long. We actually on a very regular basis will administer Narcan, wake them up, and give an IM maintenance dose before obtaining a refusal (assuming no other issues present themselves). Say what you will about it being right or wrong. One of our Level 1/Universities recently completed a study on no-transport opiate ODs with Narcan administration. No patients seen and treated by EMS were seen by the hospital or ME/Coroner within 48hrs of treatment over a 2 or 3 year period. Now our hospitals and medical director encourage this practice.


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## usalsfyre (Jul 11, 2011)

PoeticInjustice said:


> If our city transported every pt that was found as an unconscious opiate OD, our hospitals would be over-crowded and on diversion all day long. We actually on a very regular basis will administer Narcan, wake them up, and give an IM maintenance dose before obtaining a refusal (assuming no other issues present themselves). Say what you will about it being right or wrong. One of our Level 1/Universities recently completed a study on no-transport opiate ODs with Narcan administration. No patients seen and treated by EMS were seen by the hospital or ME/Coroner within 48hrs of treatment over a 2 or 3 year period. Now our hospitals and medical director encourage this practice.



But...we've established in the past the situation in your city is atypical as well.


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## TransportJockey (Jul 11, 2011)

PoeticInjustice said:


> If our city transported every pt that was found as an unconscious opiate OD, our hospitals would be over-crowded and on diversion all day long. We actually on a very regular basis will administer Narcan, wake them up, and give an IM maintenance dose before obtaining a refusal (assuming no other issues present themselves). Say what you will about it being right or wrong. One of our Level 1/Universities recently completed a study on no-transport opiate ODs with Narcan administration. No patients seen and treated by EMS were seen by the hospital or ME/Coroner within 48hrs of treatment over a 2 or 3 year period. Now our hospitals and medical director encourage this practice.



That sounds like a system I wanna work in


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## STXmedic (Jul 11, 2011)

usalsfyre said:


> But...we've established in the past the situation in your city is atypical as well.



Fair enough 



TransportJockey said:


> That sounds like a system I wanna work in



Not if you currently enjoy EMS! That's why I got my part-time job! Lol! We will hopefully be getting some big changes soon, though


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## abckidsmom (Jul 11, 2011)

I can't remember ever fighting a post-narcotic OD patient.  The lore on this one drives. me. batty.

Just the other day, I had a patient who OD'd on who knows what and had drunk a case of beer.  She was totally unconscious, with a heart rate of 160, hypotensive, and breathing mostly adequately, although not protecting her own airway.  Her pupils were sluggish at 2 mm.

I gave her 2 mg of narcan, not because I was suspecting narcotic OD (people just don't get into that much in our rural county...much more likely to be other stuff).  Anyway, I gave the narcan because I knew I'd catch heck for it in the er if I didn't give it to her.

Later, when she'd woken up some (well after the narcan dose, not related), she was fighting, and nearly hurting herself, so I ended up giving some versed to put her back into lala land.

Ends up, I caught heck in the ER because of my "ridiculous" dose of narcan which "OBVIOUSLY" was the reason she was combative.

Seriously, I've given narcan in 2 mg increments to actual narcotic ODs and the only adverse reaction has been shivering and puking.  Not so much on the fighting.  We'll save that for the post-ictal pts and the post-hypoglycemic pts.


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## shfd739 (Jul 11, 2011)

PoeticInjustice said:


> Fair enough
> 
> 
> 
> Not if you currently enjoy EMS! That's why I got my part-time job! Lol! We will hopefully be getting some big changes soon, though



Big changes????? I'm interested to see what y'all are doing. 


Sent from my electronic overbearing life controller


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## shfd739 (Jul 11, 2011)

TransportJockey said:


> This. And I think I pushed Narcan my first time 3 days after starting working as a basic. I usually will only give enough to bring their respirations back to normalish. I don't bother trying to wake up the OD most times



Same thing I do. Keep the breathing decent and let em sleep. 


Sent from my electronic overbearing life controller


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## medicdan (Jul 11, 2011)

Elk Oil said:


> I've done some searching and can't find any discussion on this, so I thought I'd throw it out there and get some of your experiences.
> 
> We all know that generally-accepted practices surrounding the use of narcan for opiate overdoses.  We've heard the prevailing philosophy that the patient (may/will) awaken and become violent.  In fact, I've worked with some EMTs who refused to administer it in the field because of their fear of what the newly-conscious patient would be like.
> 
> ...



My (limited) experience when working ALS, and seeing others use it IN BLS has been that the risk of violence is proportional to the rate you push it... if IV slamming or even brisk administration = agitation and vomiting. Slow and steady (over 2 min or so), and a smaller initial dose = calm, breathing patient.


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## STXmedic (Jul 11, 2011)

shfd739 said:


> Big changes????? I'm interested to see what y'all are doing.
> 
> 
> Sent from my electronic overbearing life controller



It'll come in three stages. Stage 1 has about 25 new medications, some being:
Adenosine
Benadryl
Fentanyl
Versed
Dopamine
Levophed
Nitro drips
And many more, plus:
IV pumps
Video laryngoscopy (Ha!)
Bougies
NG tubes

Later phases aren't set in stone yet but will contain Etomidate, Ketamine, RSI, and ultrasound.

Don't laugh at us!  We had a fairly archaic and very limiting medical director prior to our current one, so we're trying to catch up and jump ahead all at once (with appropriate steps for training of course)


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## Smash (Jul 11, 2011)

We have been administering narcan to overdoses for decades, treat and release and very, very seldom have had any issues. 
There are two key points: oxygenate well prior to administering narcan. A hypoxic head will give you an angry patient, so get them well oxygenated and well ventilated first. 
Then, give it gently. We don't even give it IV, IM is much nicer, it wakes them up slowly and smoothly, no angry, no sweating, no shaking, no vomiting.  They wake up, shake our hands and go home.
As a service we have been following this approach for about a decade or so, and have never had any issues. We also, as a service, used to see quite literally hundreds of heroin overdoses a day.


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## jwk (Jul 11, 2011)

PoeticInjustice said:


> It'll come in three stages. Stage 1 has about 25 new medications, some being:
> Adenosine
> Benadryl
> Fentanyl
> ...



I would have thought some of thse were already pretty standard issue, adenosine and benadryl in particular.


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## DesertMedic66 (Jul 11, 2011)

All the medics I have worked with so far will only push enough to keep them stable but still not conscious. Then once we pull up to the hospital they will push a little more so the patient wakes up and can answer the hospitals questions. Better to have an aggressive patient at a hospital with countless people there then to have an aggressive patient in the back of the rig when it's just you and the patient.


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## STXmedic (Jul 11, 2011)

jwk said:


> I would have thought some of thse were already pretty standard issue, adenosine and benadryl in particular.



Preaching to the choir, buddy


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## Smash (Jul 11, 2011)

firefite said:


> All the medics I have worked with so far will only push enough to keep them stable but still not conscious. Then once we pull up to the hospital they will push a little more so the patient wakes up and can answer the hospitals questions. Better to have an aggressive patient at a hospital with countless people there then to have an aggressive patient in the back of the rig when it's just you and the patient.



There is really no need to have an aggressive patient at all, anywhere. Just follow the easy two step program I outline above and they can happily wake up and go home.


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## DesertMedic66 (Jul 11, 2011)

Smash said:


> There is really no need to have an aggressive patient at all, anywhere. Just follow the easy two step program I outline above and they can happily wake up and go home.



To the most part yes. But we've had a couple of patients get aggressive because we "took their high away" and "made them waste money". No matter how you give narcan to that kind of patient, when they wake up their probably gonna be angry.


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## abckidsmom (Jul 11, 2011)

firefite said:


> To the most part yes. But we've had a couple of patients get aggressive because we "took their high away" and "made them waste money". No matter how you give narcan to that kind of patient, when they wake up their probably gonna be angry.




I always tell them if they want to fully enjoy their high, they need to warn the people around them not to call 911.  They need to blame their sorrows on the people that call, not us.


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## DesertMedic66 (Jul 11, 2011)

abckidsmom said:


> I always tell them if they want to fully enjoy their high, they need to warn the people around them not to call 911.  They need to blame their sorrows on the people that call, not us.



Ours somehow alway wonder off and we get called because they are laying on the side of the road. I've actually never responded to a OD with other people on scene. It's always just been the patient...... I wonder why lol


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## abckidsmom (Jul 11, 2011)

firefite said:


> Ours somehow alway wonder off and we get called because they are laying on the side of the road. I've actually never responded to a OD with other people on scene. It's always just been the patient...... I wonder why lol



Or just the patient with pants full of ice.  It's like a giant "Some Idiot Was Here" sign.  I love telling the people that ice thing is a total myth, but then I wonder how many people we *don't* see because the ice in the crotch woke 'em right up?


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## DesertMedic66 (Jul 11, 2011)

abckidsmom said:


> Or just the patient with pants full of ice.  It's like a giant "Some Idiot Was Here" sign.  I love telling the people that ice thing is a total myth, but then I wonder how many people we *don't* see because the ice in the crotch woke 'em right up?



I've heard of people doing that but sadly I haven't seen it yet. "be advised we are coming at you code 3 with an OD with blue balls" :rofl:


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## abckidsmom (Jul 11, 2011)

firefite said:


> I've heard of people doing that but sadly I haven't seen it yet. "be advised we are coming at you code 3 with an OD with blue balls" :rofl:



You know your response time has been long when their pants are just wet, lol.


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## mycrofft (Jul 11, 2011)

*Ice was old school, but worked sometimes.*

Probably faking, sometimes.

Elavil OD violence, though,...real.


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## ah2388 (Jul 11, 2011)

mycrofft said:


> Probably faking, sometimes.
> 
> Elavil OD violence, though,...real.



this...yikes


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## shfd739 (Jul 11, 2011)

PoeticInjustice said:


> It'll come in three stages. Stage 1 has about 25 new medications, some being:
> Adenosine
> Benadryl
> Fentanyl
> ...



Dang. I thought yall had most of that already. 



Sent from my electronic overbearing life controller


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## Chief Complaint (Jul 11, 2011)

Only pushed Narcan once, during my internship.  It was via IO.  The patient was extremely upset that we ruined her high and threatened to yank out the IO.  After explaining to her how much pain this would cause her, she calmed down....slightly.


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## 8jimi8 (Jul 11, 2011)

Great thread!


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## abckidsmom (Jul 11, 2011)

Chief Complaint said:


> Only pushed Narcan once, during my internship.  It was via IO.  The patient was extremely upset that we ruined her high and threatened to yank out the IO.  After explaining to her how much pain this would cause her, she calmed down....slightly.



This reminds me of the time some overzealous medics in our county pushed Narcan _down the ET tube_!  

Holy skill-happy medics, batman!


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## usalsfyre (Jul 11, 2011)

Chief Complaint said:


> Only pushed Narcan once, during my internship.  It was via IO.  The patient was extremely upset that we ruined her high and threatened to yank out the IO.  After explaining to her how much pain this would cause her, she calmed down....slightly.



This is one more reason to add to the list of reasons I love the IN delivery route.


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## Trevor (Jul 11, 2011)

I've never had to fight my narcotic ODs... You wanna know why??? Cause I dont give them 2 mgs of Narcan at one time... Give em enough so they are breathing effectively... 

You wanna know why they wake up puking and "shivering"? Cause you're probably sending them into withdraws...


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## Iceman26 (Jul 11, 2011)

Trevor said:


> I've never had to fight my narcotic ODs... You wanna know why??? Cause I dont give them 2 mgs of Narcan at one time... Give em enough so they are breathing effectively...
> 
> You wanna know why they wake up puking and "shivering"? Cause you're probably sending them into withdraws...



This is definitely the ideal way to do it...enough to breathe. But if they do wake up, going along with Chief Complaint's post, if they do wake up it's fun to see how ticked they are you took their high away. What would be even more fun is to tell them how cheap the Narcan is you used to take their high away, but that would just be mean.


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## Chief Complaint (Jul 11, 2011)

Indeed, 2mg was too much for this girl.  She came back immediately and had no apparent grogginess (is that a word?).  She was also pretty pissed that we cut off her clothes as they were the only clothes that she owned.  She was a street kid.


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## Smash (Jul 12, 2011)

You know, I would be pretty annoyed too if you cut up my only set of clothes when I had no way of getting more and no way of keeping warm, and then whacked a nail into a bone in order to send me rapidly into withdrawal. 

Why would you do all that?  What purpose does it serve to treat her in such a fashion?  It seems to me to be either extreme overkill or simply punitive  Maybe that's why I've never had someone come up angry: I treat them like a human being, with a bit of compassion and dignity.


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## the_negro_puppy (Jul 12, 2011)

I have never seen narcan used. Our protocols are 1.6mg IM for adults and 20 mcg/ kg IM for paeds.

Our protocols tstae it should rarely have to be used and good oxygenation/ventilation should be sufficient.

Its only indicated for respiratory depression secondary to narcotics. An altered/ ALOC pt that is not resp depressed does not get it.

We only have small numbers of heroin users here, not as popular as it used to be.,


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## Chief Complaint (Jul 12, 2011)

Smash said:


> You know, I would be pretty annoyed too if you cut up my only set of clothes when I had no way of getting more and no way of keeping warm, and then whacked a nail into a bone in order to send me rapidly into withdrawal.
> 
> Why would you do all that?  What purpose does it serve to treat her in such a fashion?  It seems to me to be either extreme overkill or simply punitive  Maybe that's why I've never had someone come up angry: I treat them like a human being, with a bit of compassion and dignity.




I was just an intern on this call so it wasnt me calling the shots.  I did as i was told.  

When we found the patient she was unconscious with a weak pulse (cant remember rate since its been so long) and respirations at 4/min.  She had very tight fitting jeans on and a tight long sleeve shirt that extended past her hands.  Her clothes were cut off for 2 reasons, in an attempt to find a suitable vein for IV access, and to attach the leads for an EKG.

Again, i only did as i was told since i was just an intern on a ride along.


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## usafmedic45 (Jul 12, 2011)

> This reminds me of the time some overzealous medics in our county pushed Narcan down the ET tube!



Eh....not a huge deal.  I used to give it via a sublingual injection in patients without IV access.


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## Iceman26 (Jul 12, 2011)

Chief Complaint said:


> I was just an intern on this call so it wasnt me calling the shots.  I did as i was told.
> 
> When we found the patient she was unconscious with a weak pulse (cant remember rate since its been so long) and respirations at 4/min.  She had very tight fitting jeans on and a tight long sleeve shirt that extended past her hands.  Her clothes were cut off for 2 reasons, in an attempt to find a suitable vein for IV access, and to attach the leads for an EKG.
> 
> Again, i only did as i was told since i was just an intern on a ride along.



When you come across a patient like this there's nothing wrong with exposing them, not only for the sake of finding an IV but you have no idea why they're down. You need to be able to assess their entire body. Obviously depending on the kind of clothing there are different ways you can do it, you want to maintain some decency and respect for them (obviously have blankets handy to promptly cover them up) but you need to see if there's a trauma or other reason this person is down. It always looks great when you take someone to the hospital and report no injuries and then the hospital staff exposes the patient and finds something you missed because you didn't expose them and get a proper assessment. I've seen it happen and it's not good. 

As for the use of an IO, it's common practice and in most people's protocols. You obviously attempt regular IV access first, and some would opt for an EJ before an IO but there's nothing "wrong" with using one if it's that or no IV access at all. It's in the protocols for a reason.


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## dixie_flatline (Jul 12, 2011)

I didn't quite read every post, but thought I'd throw out my (admittedly Basic) experiences.  I've been on 2 or 3 calls in the past few months where we pushed narcan (we use IN narcan - does anyone else?).  I think that a lot of the "come up swinging" stories might stem from providers instigating.  

This is just a theory, but the really depressed opiate ODs I've been on, the narcan does bring them up in a few minutes, but they're usually disoriented, confused, and their body is obviously feeling a bit of a system shock.  A lot of providers seem to talk down to, or ignore, the pt who almost always has a lot of questions, is worried about the cops, etc.  Having some (ahem) patience with the patients seems to curb the so-called violent tendencies.


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## 8jimi8 (Jul 12, 2011)

Chief Complaint said:


> I was just an intern on this call so it wasnt me calling the shots.  I did as i was told.
> 
> When we found the patient she was unconscious with a weak pulse (cant remember rate since its been so long) and respirations at 4/min.  She had very tight fitting jeans on and a tight long sleeve shirt that extended past her hands.  Her clothes were cut off for 2 reasons, in an attempt to find a suitable vein for IV access, and to attach the leads for an EKG.
> 
> Again, i only did as i was told since i was just an intern on a ride along.



I'm not trashing you, Bro, but that didn't work in the nuremberg trials.  Following orders is no reason to follow illegal orders.


***not to say that exposing the patient isn't proper.


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## usafmedic45 (Jul 12, 2011)

8jimi8 said:


> I'm not trashing you, Bro, but that didn't work in the nuremberg trials.  Following orders is no reason to follow illegal orders.
> 
> 
> ***not to say that exposing the patient isn't proper.





...and time to lock the thread.  :rofl:


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## Iceman26 (Jul 12, 2011)

dixie_flatline said:


> I didn't quite read every post, but thought I'd throw out my (admittedly Basic) experiences.  I've been on 2 or 3 calls in the past few months where we pushed narcan *(we use IN narcan - does anyone else?)*.  I think that a lot of the "come up swinging" stories might stem from providers instigating.
> 
> This is just a theory, but the really depressed opiate ODs I've been on, the narcan does bring them up in a few minutes, but they're usually disoriented, confused, and their body is obviously feeling a bit of a system shock.  A lot of providers seem to talk down to, or ignore, the pt who almost always has a lot of questions, is worried about the cops, etc.  Having some (ahem) patience with the patients seems to curb the so-called violent tendencies.



Yeah it's in our protocols to do so.


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## MrBrown (Jul 12, 2011)

Frusemide:  Hey bro, what are you doing here?
Naloxone:  I'm not wanted either bro!
Lidocaine:  Aw man, not another one!
Bretylium:  Yeah man its getting crowded in here!


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## usalsfyre (Jul 12, 2011)

MrBrown said:


> Frusemide:  Hey bro, what are you doing here?
> Naloxone:  I'm not wanted either bro!
> Lidocaine:  Aw man, not another one!
> Bretylium:  Yeah man its getting crowded in here!



Procainamide: Everyone forgets about me!

Verapamil: At least you don't have "kill" in your nickname...


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## Chief Complaint (Jul 12, 2011)

8jimi8 said:


> I'm not trashing you, Bro, but that didn't work in the nuremberg trials.  Following orders is no reason to follow illegal orders.
> 
> 
> ***not to say that exposing the patient isn't proper.



I know you arent, i didnt mean to sound so defensive.

If they had asked me to do something that wasnt in my scope or that i didnt feel was appropriate, i wouldnt have done it.  I didnt feel that exposing the patient would be detrimental so i went ahead and did it.


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## usafmedic45 (Jul 12, 2011)

usalsfyre said:


> Procainamide: Everyone forgets about me!
> 
> Verapamil: At least you don't have "kill" in your nickname...


Isoproterenol:  'Bout damn time you guys got here.


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## 8jimi8 (Jul 12, 2011)

Chief Complaint said:


> I know you arent, i didnt mean to sound so defensive.
> 
> If they had asked me to do something that wasnt in my scope or that i didnt feel was appropriate, i wouldnt have done it.  I didnt feel that exposing the patient would be detrimental so i went ahead and did it.



i didn't see you being defensive.  i also posted this in between sleep sessions this morning.  so i don't even see what illegal orders we were talking about anymore haha.

this is a large hint not to sleep with my phone laying next to me in the bed.


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## MotorCity (Jul 13, 2011)

Ok hears what I've learned over the years working in a few different places (private, paid on call ALS, big city). Most common thing that leads to fighting is giving Narcan to an A&Ox4 pt who is high on a narcotic. They are fully aware that you are taking away there "high". 

Second, "slamming" Narcan leads to immediate puking and probably 50% chance fighting. 

Here is my rule and what I'm starting to see as our new state protocol. Narcan is given for altered mental status, and DECREASED RESPIRATIONS.  You may or may not have other findings.   But if you do not have these two there is no need for Narcan. All you need is 0.4mg in almost every situation. Start there give it 2 minutes or so while assisting respirations with BVM. If that does not work give another 0.4mg until you improve respiration then stop. No need to totally wake the pt while in there house, ally, or whatever. I guarantee if you give enough to improve respirations the pt will be alert on arrival to hospital. 

Sometimes fighting is inevitable. If you feel like this is going to be the one. Restrain the pt prior to Narcan if protocol allows. 


P.S. Stop saying Narcan is for opiate OD. Narcan is for narcotic overdoses. A narcotic is anything derived from Opium, synthetic (opioid) or natural (opiate). Please look it up if you don't believe me. 
If you have any resource to prove this wrong please let me know because I would feel like a real dumb butt if I was wrong about this


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## Aidey (Jul 13, 2011)

Narcotic is an ambigious term and it isn't really used in proper pharmacology. It used to mean any mind altering substance, not just opioid based compounds. 

Also, all opiates are opioids, but not all opioids are opiates, so really we should be using opioid in this discussion. However, few people bother to differentiate between the two in casual conversation, and I doubt people are going to start now.


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## MotorCity (Jul 13, 2011)

I know I know. Law enforcement generalized the meaning of narcotic to mean any illegal drug. That is becoming the standard use now.


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## lightsandsirens5 (Jul 13, 2011)

usafmedic45 said:


> ...and time to lock the thread.  :rofl:



I know!

Unfortunately it is a very productive and informative thread so far, so we'll just let Godwin sleep through this one.


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## the_negro_puppy (Jul 13, 2011)

Why are people pushing for immediate IV access for a suspected opioid overdose? why not push IM/IN narcan first while managing airway/ventilation and see the pt's response before cutting up clothes and starting lines.


We are instructed that IV access should not normally be attempted done with opioid overdoses unless there are other complications and naloxone doesnt work.


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## Smash (Jul 13, 2011)

Chief Complaint said:


> I was just an intern on this call so it wasnt me calling the shots.  I did as i was told.
> 
> When we found the patient she was unconscious with a weak pulse (cant remember rate since its been so long) and respirations at 4/min.  She had very tight fitting jeans on and a tight long sleeve shirt that extended past her hands.  Her clothes were cut off for 2 reasons, in an attempt to find a suitable vein for IV access, and to attach the leads for an EKG.
> 
> Again, i only did as i was told since i was just an intern on a ride along.



What is was her actual problem when you arrived?  Would hypoxia secondary to respiratory depression sound reasonable?
If so, why not ventilate and oxygenate her.  Problem solved.  Then you can attach ECG leads to wrists and ankles (they are limb leads you know) and either administer some IN or IM naloxone.  Or you could roll her sleeves up to find an IV site if you absolutely must give IV naloxone.

I accept that you were an intern then; what would you do in the same situation now?


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## usafmedic45 (Jul 13, 2011)

> Why are people pushing for immediate IV access for a suspected opioid overdose? why not push IM/IN narcan first while managing airway/ventilation and see the pt's response before cutting up clothes and starting lines.



Yup.  That's pretty much my approach.


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## Smash (Jul 13, 2011)

the_negro_puppy said:


> Why are people pushing for immediate IV access for a suspected opioid overdose? why not push IM/IN narcan first while managing airway/ventilation and see the pt's response before cutting up clothes and starting lines.
> 
> 
> We are instructed that IV access should not normally be attempted done with opioid overdoses unless there are other complications and naloxone doesnt work.



I have a nasty suspicion that it is punitive, especially when people are talking about starting an IO for what seems just to be :censored::censored::censored::censored:s and giggles.


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## Melclin (Jul 14, 2011)

I must typed a pile of responses last night and just not sent them.


IO narcan? How absurd. 

IM first choice. I have heard that when they've been down long enough, esp in a cold environment you have to give it a while and maybe top it up but it certainly works well. My experience is limited with it but the first time I gave it, the bloke came a shook my hand and thanked me afterwards. I've never seen anyone get pissed off, just look a little crook. 

I've been interested in IN route for a while because I like the idea of not having to wield a needle around that I've just stuck in a hep c pt. But if I remember correctly, there were some issues with the concentration of the preparations currently available in that its a little too dilute for IN. Still works, just not as well.

Wouldn't the IN route be a little faster and therefore less desirable?


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## MrBrown (Jul 14, 2011)

Gosh you MAS blokes are a bit behind the times, we have IN naloxone, 12 lead interpretation, paediatric cannulation and cardioversion at Paramedic level, ketamine, you name it.

What would Frank Archer say?


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## Melclin (Jul 14, 2011)

Probably that most of those issues are budgetary :wacko:


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## Melbourne MICA (Jul 14, 2011)

*Bonjourno Mr Brown*



MrBrown said:


> Gosh you MAS blokes are a bit behind the times, we have IN naloxone, 12 lead interpretation, paediatric cannulation and cardioversion at Paramedic level, ketamine, you name it.
> 
> What would Frank Archer say?



Now don't you go casting as as a bunch of illiterate reactionaries. It may be true is some cases but not yours truly even if i think progress peaked with frozen pizza.

Now Mr Meclin - naughty boy and no offence intended for following - have you finished the ambo course yet? If so I think you are in about your first of second year at most. The problem you get into when discussing past history or subjects where past experiences add flavour to the subject is you actually have to have had past experiences as an ambo.

Now for Mr Browns info - we trialled IN Narcan some years ago - didn't go on with it - too much wastage, cost issues and the IM route has been highly effective and stilll is.

We also have 12lead, Ketamine, cardioversion, paeds cannulation you name it - but not for the roadies - MICA only. The ALS Paramedics have a lot of ALS skills but there's 3500 ambos in Victoria now, >50% are students, >50% are less than 23yrs old and in our zeal to put bums on seats for response times our organisation has been happy to drop the bar a fair bit or liberally interpret what passes as competencies. 

Don't get me wrong there are some outstanding graduates of the Uni courses but there's also far too many staff lacking anything that could be called life or work experience -some are in their first full time job, first car etc.

Anyway - IM Narcan route - has had great success - we used to go IV, the MICA oldies would stop roadies from bagging up the OD pts, so they had time to pop the line in and give a dose. So you wound up with hypoxic, cranky, hostile junkies who felt like S#*t and were ready to smack the first head that came into view. There was also a lot of needle stick risk and actual incidents.
Big OH&S issue

No more. IM  -everyone can give it, slow onset, plenty of time to bag up the patient and resolve the hypoxia, gentle gentle gentle - now the pts say sorry for wasting our time. It's all very low key, easy does it with no-one put at risk - No of needle stick injuries  - virtually zero.

One of the best changes to our guidelines I think we've ever done.

MM


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## Melclin (Jul 14, 2011)

Melbourne MICA said:


> Now Mr Meclin - naughty boy and no offence intended for following - have you finished the ambo course yet? If so I think you are in about your first of second year at most. The problem you get into when discussing past history or subjects where past experiences add flavour to the subject is you actually have to have had past experiences as an ambo.



I completely agree and I'm more than a little confused at this reply. Its very hard to discuss past history without having been there to actually know what happened. But where did I actually claim to know anything about the past? When I said "If I remember correctly...", I meant it in regards to the _literature_, not any actual experience and in fairness, I specifically stated that my _experience_ with it was limited. 

I have strong opinions on academic matters and I'm reasonably well read, but thats it, and thats all I lay claim too.


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## Melbourne MICA (Jul 14, 2011)

Melclin said:


> I completely agree and I'm more than a little confused at this reply. Its very hard to discuss past history without having been there to actually know what happened. But where did I actually claim to know anything about the past? When I said "If I remember correctly...", I meant it in regards to the _literature_, not any actual experience and in fairness, I specifically stated that my _experience_ with it was limited.
> 
> I have strong opinions on academic matters and I'm reasonably well read, but thats it, and thats all I lay claim too.



And I also said no offence intended and it wasn't. But the decisions that led to our IM Narcan protocol had nothing to do with cost. They were based on OH&S issues. The IN Narcan trial we had here In Melbourne was undertaken from memory about 6 years ago. 

There were OH&S issues involved as well - getting rid of sharps in drug situations was rightfully seen  as a good goal to strive towards but when the situtation was examined the pts faired no better with IN narcan and the incidence of needlestick was so negligible with IM - the troops were experienced in using it and knew when to jab or not to jab - that with the extra cost and practical issues like measuring out the right amount it was decided to keep the guideline as it was. So IN Narcan was dumped.

But a lot (most) of the discussions here relate to field work. There is always academic content of course but I guess I' m just saying there is a difference between the two. Sometimes its better to just ask questions than provide answers if you are looking to pick up something useful you can apply in the field. There are a lot of "tricks of the trade" in EMS - some good, some not so good. A solely academic perspective often doesn't illuminate the difference

MM


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## Melclin (Jul 14, 2011)

Melbourne MICA said:


> And I also said no offence intended and it wasn't. But the decisions that led to our IM Narcan protocol had nothing to do with cost. They were based on OH&S issues.
> 
> ....
> 
> ...



I wasn't refering to the IM narcan when I mentioned cost. I was talking more about the 12-lead stuff. Partly in terms of the equipment, but more so in terms of how much it was cost to train everyone up to that standard and then meet the ever present demands for increased pay for increased skill sets. But it was also just a a throw away line in relation to the fact that I knew brown was just kidding.

I know you weren't trying to offend, I guess I'm just a little sensitive of being accused of being one of "those grads" who think they are god's gift to ambulance practice from day one. The hostile climate that those students have left/continue to leave for other grads who happily recognise the value of experience (and how little experience we ourselves have) is, frankly, quite difficult to deal with.

As it happens, I'd appreciate your input on my hyper-G question in stroke if you have the time, given that you're part of our system.


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## mycrofft (Jul 14, 2011)

*IMHE (very limited as to succeful Narcan but lotsa drugs and pseudos)*

1. MANY abusers are also using other chemicals, at least in USA. They may have pinpoint pupils or not, but if there is respiratory compromise and other signs congruent with CNS depression, we will tend to do some Narcan. The underlying alcohol, methamphetamines, and other trash may become more evident, along with the attendant toxic psychoses.
2. If a person is a combative sort, and especially if you "wake 'em up" to a hostile and confusing environment, they will tend to flail, be it from sleep, diabetic coma, alcoholic stupor, or OD.
3. Amazing how some people with unconsciousness but normal or nearly normal VS will suddenly "flail" but always manage to hit you on the torso, face or neck? Or suddenly "wake up", and grab on, impaling you on their long grimy fingernails where you are not wearing clothing? Yeah, how very coincidental.


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## usafmedic45 (Jul 14, 2011)

> IM first choice. I have heard that when they've been down long enough, esp in a cold environment you have to give it a while and maybe top it up but it certainly works well.



That's why sublingual injection works so well.  It is largely unaffected by peripheral vasoconstrition and the veins of the tongue drain fairly directly into the jugular veins.


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## Smash (Jul 14, 2011)

Melbourne MICA said:


> We also have... Ketamine



Except you don't have ketamine.  The flyboys do, you don't 



mycrofft said:


> 1. MANY abusers are also using other chemicals, at least in USA. They may have pinpoint pupils or not, but if there is respiratory compromise and other signs congruent with CNS depression, we will tend to do some Narcan. The underlying alcohol, methamphetamines, and other trash may become more evident, along with the attendant toxic psychoses.



We are lucky in that most of our heroin overdoses are pure heroin, maybe with a little benzo thrown in.  It's unusual to find patients speedballing.  That said, if I suspect a polypharmacy overdose, or that the patient has been down for a long time, I tend to go down the "manage airway, ventilate and transport" route rather than cause us all more issues in the field.  If it's a straight forward opioid/opiate/narcotic (did I cover them all?) OD then they can wake up and go home.


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## Iceman26 (Jul 14, 2011)

For the record when I was referring to IO's being in protocols I wasn't suggesting they be used for Narcan. I was talking just their use in general, there are situations where they're warranted. Strictly for the use of Narcan is not one of them.


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## STXmedic (Jul 14, 2011)

Iceman26 said:


> For the record when I was referring to IO's being in protocols I wasn't suggesting they be used for Narcan. I was talking just their use in general, there are situations where they're warranted. Strictly for the use of Narcan is not one of them.



Agreed. IOs can be nice at times... but IO Narcan is ridiculous!!


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## emtchick171 (Jul 14, 2011)

Personally, I like narcan for opiate overdose patients. There have been times that my patient's have became irritated, and became combative, also they will vomit sometimes. It all depends on how dependent the patient has become on an opiate, it also has a lot to do with how fast you push the narcan. If you titrate the dose...usually you will have a problem free procedure.


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## usalsfyre (Jul 14, 2011)

emtchick171 said:


> Personally, I like narcan for opiate overdose patients. There have been times that my patient's have became irritated, and became combative, also they will vomit sometimes. It all depends on how dependent the patient has become on an opiate, it also has a lot to do with how fast you push the narcan. If you titrate the dose...usually you will have a problem free procedure.



If your frequently encountering these side effects, why do you like the med?


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## Sam Adams (Jul 14, 2011)

From experience, multiple experiences, opiate OD's reversed with narcan can become combative. For those of you naive enough to think otherwise, I pray it doesn't happen when you're not expecting it. 

Smash gave some excellent pointers to combat/ prevent the comabativeness.

I'll add, IN administration seems to have to slowest onset and therefore GRADUALLY reverses the OD. The patient isn't stoned one second and awake and vomiting the next (as seen when it's "slammed" by vindictive medics). In addition, I've found that pt's deal better "waking up" where they passed out. They shoot up in a bathroom, wake them up in the bathroom, not in the lighted environment of an ambulance staring up and a stranger, with a piece of plastic in their mouths that's causing them to gag.


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## emtchick171 (Jul 14, 2011)

usalsfyre said:


> If your frequently encountering these side effects, why do you like the med?



I didn't say I "frequently" experienced them. I said "there have been times". I don't push narcan fast therefore I don't usually experience problems.


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## nemedic (Jul 14, 2011)

I love IN narcan. for basics in MA, as long as your company has the special project waiver (mine does), the protocol allows basics IN 2mg on orders, with a call to the big doc in the sky for another 2mg. more than that and the medics should already be there and have, or be setting up a line. and my method of choice is nice and slow, and generally after we have them packaged.


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## MrBrown (Jul 15, 2011)

Brown doesn't really think we should be waking up overdoses to be honest.

Nana who has chronic pain syndrome and scoffed down a few too many oral morphine tablets by mistake one morning maybe .... coz she can stay at home with Grandpa to look after her and she can see the pain management clinic about that in the am.


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## Too Old To Work (Jul 15, 2011)

I haven't given IV Narcan in probably 12-15 years. IM is much better as it's absorbtion is slower. We also don't give more than 1mg IM as a general rule. The patient wakes up much more gradually, is less likely to vomit, less likely to be at all agitated, and way less likely to develop Pulmonary Edema. The last is pretty rare but it does happen. 

IN might be even better, but I haven't used it enough yet to really say.


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## Aidey (Jul 15, 2011)

I have given narcan IM, IN and IV. Route is generally based on patient presentation. 

I really have never had someone wake up swinging. The closest was someone who had aspirated and was freaking out because she couldn't breathe. Most of the time we end up going through the "I don't do heroin" skit.


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## Smash (Jul 15, 2011)

MrBrown said:


> Brown doesn't really think we should be waking up overdoses to be honest.
> 
> Nana who has chronic pain syndrome and scoffed down a few too many oral morphine tablets by mistake one morning maybe .... coz she can stay at home with Grandpa to look after her and she can see the pain management clinic about that in the am.



There are definite arguments against waking everyone up, however there are equally valid arguments for it.  I am lead to understand that in the late 80s and 90s in Sydney and Melbourne there was a veritable epidemic of heroin, with hundreds of patients overdosing every week in each city.  The logistics of taking all of them to hospital would have been quite simply overwhelming.  It is impossible to imagine how a hospital would cope with 20 ventilated patients a day on top of their normal workload.  

Therefore I believe that the practice of waking them up and sending them on their way was reasonable and did not result in problems for the patients or the service.  It is this that I have based my practice off.


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## Melbourne MICA (Jul 17, 2011)

*Gently does it*

Our experience here in Melbourne has been to see dangerous confrontations with Heroin OD's virtually disappear. Depending where you work, Heroin Od's are a daily occurence - went to one this week. At their peak when everyone involved in the Afgan war was trying to make money, we could easily do 3 or 4Heroin OD'S each and every shift - thats just one branch and one shift crew. It was everywhere. Far less so now but nonetheless all too regular.

Our guideline was changed years ago from MICA only IV Narcan with road crews watching on to everyone with IM Narcan and more importantly, emphasis on BVM ventilation and managing hypoxia first. Our doses are 1.6-2.0mg IM with MICA able to give a few more 400mcgm IV doses if needed. It rarely is.

And because we ventilate and give modest doses of Narcan slowly there is no imposed withdrawl syndrome and subsequent pallor, nausea, vomiting, tachy - feeling generally like crap and ready to take it out on someone.

Our O'ds wake up slowly and almost always refuse to go to hospital. Why? Because they are fully awake with no hypoxic hangover or withdrawl symptoms. They feel OK and most often are walking around the room apologising to others or just saying: "sh*t - did I really OD?" 

We are happy to leave them be provided there is another half responsible person there to keep an eye on them. No recalls for ambulance, no hospital beds taken up, the user out of harms way but not being hassled by anyone.

Its been and remains a highly effective arrangement - and if you are local you start to realise the local users don't ever hassle you because you don't do it to them.

We know most will use again and occasionally there is a death, or hypoxic brain injury event. We always talk to them and to others around them, give some friendly advice and then get out of their faces.

My perception on this from 15 yrs working in the same area is we have earned their respect. Few Melbourne heroin users give ambos crap because of it.

(Now the amphets, GHB and alcohol is another story)

I've said it before but I think the changes to our Heroin OD guidleines are probably one of the best we ever did.

MM


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## MrBrown (Jul 17, 2011)

Brown completely agrees, and so do Browns ex heroin addict parents.

Heroin virtually disappeared overnight in the early 1990s here when everybody got on free methadone and clonnies.  A heroin overdose here is now extremely rare, once in a career event.

Now, pissed young people who have OD on alcohol and GHB so cannot control their own airway and are vomiting on you while their mates who have vomited all over themselves give you lip and threats about treating their mate on the other hand, are unfortunately not once in a career events, more like once an hour between Wednesday midnight and the following Tuesday at 10pm when the students get paid.


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## tmisbell (Jul 17, 2011)

I just make it a point to take a minute to use soft restraints to the hands and arms prior to giving narcan.  also you can give it slowly and stop when you get them breathing and alert again.


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## MrBrown (Jul 17, 2011)

tmisbell said:


> I just make it a point to take a minute to use soft restraints to the hands and arms prior to giving narcan



Oh come on mate you can't be bloody serious that's wrong on so many levels


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## lightsandsirens5 (Jul 17, 2011)

tmisbell said:


> I just make it a point to take a minute to use soft restraints to the hands and arms prior to giving narcan.



Ummmmmm......noooooooooooooo!!!!! No no no no no! Please tell me you aren't serious! 



> also you can give it slowly and stop when you get them breathing and alert again.



THIS is how you are SUPPOSED to use narcan! The point is not to "wake them up." It is to restore respiratory drive. Personally, if I have an opiate based OD, I get a line in and a vial of Naloxone out, but until I get close to losing respiratory drive, I don't give it. When I do give it, I only give just enough to restore the respiratory drive and get them to respond to verbal (maybe loud verbal). Keep them in that drug induced stupor. As long as they are stable and all, it helps keep them calm and makes your job easier. 

It is truly appalling, the number of EMS providers who look at the drug as a way to punish, to ruin a drug high. Sorry folks, that is sick. That pt is a human being. Yes they are messed up, but using a drug to willfully torture someone is disgusting, unethical and borderline evil. Reminiscent of some sadist mid-evil (how the heck is that really spelled) tyrant. 

Ok, maybe I exaggerate, but my point is none the less valid. Use the drug as it is intended, to HELP, not to torture psychologically. 




Sent from a small, handheld electronic device that somehow manages to consume vast amounts of my time. Also know as a smart phone.


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## JeffDHMC (Jul 17, 2011)

I can't count how many times I've given narcan. I can tell you that I've never seen a heroin OD become combative or withdrawal (though I love it when they deny drug use). The ones that have potential for withdrawal (at least that I've seen) are the methadone pts or those being treated chronically with narcs. I'm with most here; give enough to breath and call it good. We're not to the point of cutting them loose after waking them up, though.

Jeff


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## tmisbell (Jul 17, 2011)

MrBrown said:


> Oh come on mate you can't be bloody serious that's wrong on so many levels


I saw my partner get hit right square between the eyes.  I also know a nurse that suffered a broken arm...Ensure Scene safety.  You can let him loose later on once he wakes up and realizes you are there to help.


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## usalsfyre (Jul 17, 2011)

tmisbell said:


> I saw my partner get hit right square between the eyes.  I also know a nurse that suffered a broken arm...Ensure Scene safety.  You can let him loose later on once he wakes up and realizes you are there to help.


Why do I get the feeling these were the consequences for poor administration technique...

Do you routinely tie your diabetics down too?


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## the_negro_puppy (Jul 17, 2011)

tmisbell said:


> I saw my partner get hit right square between the eyes.  I also know a nurse that suffered a broken arm...Ensure Scene safety.  You can let him loose later on once he wakes up and realizes you are there to help.



Scene safety can easily be ensured by administering the drug, watching their reaction and getting ready to back off if they start becoming aggressive Tying down patients may only piss them off more.

I've always said it's not my job to risk injury by trying restrain or get physical with patients. That's the job of the police, or an ICP that can sedate chemically. If anyone wants to leave and threatens violence to myself or partner while we are alone i'll gladly open the Ambulance doors and help them GTFO.


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## TransportJockey (Jul 17, 2011)

tmisbell said:


> I saw my partner get hit right square between the eyes.  I also know a nurse that suffered a broken arm...Ensure Scene safety.  You can let him loose later on once he wakes up and realizes you are there to help.



This is why I don't bother waking them up. No need to tie them down (SERIOUSLY?) and not much more risk to myself or my partner. 
My thoughts for opiate OD :
"They breathing enough relatively normal?"
"Yep"
"K, lets keep them that way and go"


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## ffemt8978 (Jul 17, 2011)

TransportJockey said:


> This is why I don't bother waking them up. No need to tie them down (SERIOUSLY?) and not much more risk to myself or my partner.
> My thoughts for opiate OD :
> "They breathing enough relatively normal?"
> "Yep"
> "K, lets keep them that way and go"



Yep, let the ER wake them up.


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## Aidey (Jul 17, 2011)

I wonder where the "all or nothing" mentality has come from. Narcan and D50 are both good examples of medications that should be dosed low but routinely get dosed at the max recomended. 

I tend to give narcan IN more often than the other routes so the side effects from IV administration aren't generally a problem. However if I were to suggest around here that we should be giving it IN or IM and avoiding IV people would think I had lost it.


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## usalsfyre (Jul 17, 2011)

Aidey said:


> I wonder where the "all or nothing" mentality has come from. Narcan and D50 are both good examples of medications that should be dosed low but routinely get dosed at the max recomended.



D50 because it's routinely taught as "one amp" after medic school, at least around here. I've talked to medics who honestly don't know how much dextrose is in a prefill.

My theory on naloxene is it was given so often as a "coma cocktail" drug with no effect, combined with the sadistic mentality of "ruining the high" has lead to routinely slamming two mgs.


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## the_negro_puppy (Jul 17, 2011)

Aidey said:


> I wonder where the "all or nothing" mentality has come from. Narcan and D50 are both good examples of medications that should be dosed low but routinely get dosed at the max recomended.
> 
> I tend to give narcan IN more often than the other routes so the side effects from IV administration aren't generally a problem. However if I were to suggest around here that we should be giving it IN or IM and avoiding IV people would think I had lost it.



W effectivly titrate Glucose 10% on the pt's response. 150ml bolus then 100ml boluses every 5 minutes while the patients BSL is less than 4.0 mmol.

Naloxone however we have a standard dose for all adult patients which is 1.6mg IM given in 2 x 2ml (800mcg) syringes.


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## Dougy (Jul 17, 2011)

Linuss said:


> I try not to slam Narcan.  I push it slowly to return normal respiration / maybe wake them slowly.    Groggy patient = a losing patient in a fight.
> 
> 
> 
> I've had more trouble with postictal patients....



The medics I ride with push just enough to get them awake enough to nod their head yes or no.. no serious coherence.


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## TransportJockey (Jul 17, 2011)

Dougy said:


> The medics I ride with push just enough to get them awake enough to nod their head yes or no.. no serious coherence.



That's on the upper end of my dosing too. I try to teach my basics I ride with that when they give it, that's about all the reaction we want to see. I still had a basic a few weeks back I had a nice talking to about since he decided hot shotting the patient right outside the ED doors was a smart thing to do... Last time I let him attend an OD.


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## usalsfyre (Jul 17, 2011)

TransportJockey said:


> That's on the upper end of my dosing too. I try to teach my basics I ride with that when they give it, that's about all the reaction we want to see. I still had a basic a few weeks back I had a nice talking to about since he decided hot shotting the patient right outside the ED doors was a smart thing to do... Last time I let him attend an OD.



That's how people get punched in the face and their arms broken :unsure:...


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## firetender (Jul 18, 2011)

*There was this neighborhood...*

...where heroin OD was somewhat routine and it must have been good stuff because on our arrival, the pts. were pulseless and apneic. We didn't know better back then, but pushing the full Magilla was the standing order.

We had enough snap-backs into consciousness and running syndrome (sometimes strongarming their way out the door!) that once the resurrected was out of sight, we'd sit down, relax and wait the 20 minutes it usually took for the Narcan to wear off. We'd sit and wait for that inevitable "Man down; unknown origin" call within just a few blocks of us.

At THAT scene, we'd restrain first by an outdated method that I'm sure has been proven deadly by now, before we transported.

(We're talking around 1980 here.  The damage has already been done and I have repented since so don't pick on me!)


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## JeffDHMC (Jul 18, 2011)

Scoop sandwich, I'll wager...or something along those lines. Yeah, I've asked for forgiveness too.


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## firetender (Jul 18, 2011)

(I had ZERO problems with the Scoop Sandwich and none of my patients were ever harmed by it; I think it may have been the way I used padding!)


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## JeffDHMC (Jul 18, 2011)

You're showing your age.

Jeff


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## mycrofft (Jul 18, 2011)

*I think a thread about "movement restriction" is needed.*

Some pts could experience (i.e., "die") from positional asphyxiation or secretion aspiration when forced to lie supine. Anecdotal evidence seems to strongly suggest that some types of drug mania cases can succumb if forced into a posture of aquiescence (sandwiched, or bent double and manacled to a floor grating). This sort of violates the "do no harm" deal I think. Related deaths in EMS (and sometimes law enforcement booking areas and holding cells) can be attributed to the drugs or an unforseeable physical problem (arrythmia, asthma/COPD, obesity, airway abnormality) and the iatrogenic nature of the death or disability (due to anoxia, rhabdomyolysis, etc) missed or swept away.

LE has the "prostraint chair". Maybe we need one that holds then pt in a HAINES position? (One-third serious here).







(I apologize for size. Used without permission).


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## MrBrown (Jul 18, 2011)

Anybody who feels it necessary to prophylactically restrain an overdose patient before waking them up is a piss poor ambo who should be forever banned from practising


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## mycrofft (Jul 18, 2011)

*The prostraint chair has little wheels and a trailer hitch....*

Sorry, the photo above previewed ok but farted out in real world.


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## Melbourne MICA (Jul 18, 2011)

mycrofft said:


> Some pts could experience (i.e., "die") from positional asphyxiation or secretion aspiration when forced to lie supine. Anecdotal evidence seems to strongly suggest that some types of drug mania cases can succumb if forced into a posture of aquiescence (sandwiched, or bent double and manacled to a floor grating). This sort of violates the "do no harm" deal I think. Related deaths in EMS (and sometimes law enforcement booking areas and holding cells) can be attributed to the drugs or an unforseeable physical problem (arrythmia, asthma/COPD, obesity, airway abnormality) and the iatrogenic nature of the death or disability (due to anoxia, rhabdomyolysis, etc) missed or swept away.
> 
> LE has the "prostraint chair". Maybe we need one that holds then pt in a HAINES position? (One-third serious here).
> 
> ...





MrBrown said:


> Anybody who feels it necessary to prophylactically restrain an overdose patient before waking them up is a piss poor ambo who should be forever banned from practising



Ditto both these comments.


I've never seen a "scoop sandwich" but it sounds postitively medieaval. I'm glad  Mr Brown was so frank and Mr Mycrofft so typically on the money.

What the hell are we talking about here? Heroin OD's for gods sake.

What is a Heroin OD? Any heroin user who has used and is still awake and talking or moving around has not O'D. They may go "on the nod" as the users call it, drifting off but still with it and easily roused. Gee thats what opiates do don't they and why the users take the stuff?

When do we get called? When they stop breathing and are unconscious and unrouseable. So what part of managing an unconscious, unrouseable, non-breathing heavily narcotised patient requires the kind of preposterous approaches I'm hearing here?

They take an OP straight down the gullet with no gag do they not - hint hint - this guy will not wake up when you handle him.

Start bagging, get his sats good - in the meantime your partner has organised his IM jab of Narcan - not so much as a flinch - he's limp for gods sake. Get a BP, auscultate, dot him up and keep bagging while the Narcan takes effect.

All this crap about keeping them unconscious - good luck if you think only the pts resps will pick up but not the GCS at the same time. Your reversing all the effects of the opiates not just the resp depression.

We all certainly need to be safe in such situations of course so we keep our wits about us.  But strong arm tactics would fire anyone up especially if they feel vulnerable and threatended -like walking up to find themselves locked down in some contraption or having their limbs restrained.

I think some of the comments I've heard here are seriously off the mark.

MM


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## TransportJockey (Jul 18, 2011)

Melbourne MICA said:


> Ditto both these comments.
> 
> 
> I've never seen a "scoop sandwich" but it sounds postitively medieaval. I'm glad  Mr Brown was so frank and Mr Mycrofft so typically on the money.
> ...


You have more education and training than me, so I hesitate to call you out on medical information... but it IS possible to titrate to RR w/out getting too much increasing of GCS. I've done it several times. Usually with IV narcan not IM/SQ though.


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## Melbourne MICA (Jul 18, 2011)

*Od*



TransportJockey said:


> You have more education and training than me, so I hesitate to call you out on medical information... but it IS possible to titrate to RR w/out getting too much increasing of GCS. I've done it several times. Usually with IV narcan not IM/SQ though.



But why do you need to do that in the first place? Its ridiculous - no offense.
My experience is the GCS improvement nearly always follows the RR but this whole approach seems like a great way to get yourself in the s*#t when the pt wakes up in your rig. After all we can never know the strength or quantity of Heroin the user has taken, nor what other drugs they have used. So you will never know when to expect them waking up.

The biggest safety advantage of waking them up at the scene is you can exit on the fly if the pt arcs up - he is still drugged and slow. If you're in the rig or carrying them out to it - well good luck.

Believe it or not I think you can establish a reputation with local drug communities. If they know the ambos always treat them with respect, don't have the cops around them, don't hang s##t on them, don't manhandle or strongarm them you are engendering a relationship where there is far less likelihood of trouble.

I've done hundreds of Heroin O'D's and still do them - 2 in the last 3 shifts. I've never been hit and the handful of occasions where the pt arced up were almost entirely when we used the old IV Narcan first - keep them unconscious and restrained approach.

Heroin O'D's don't have to go the ED if they respond to treatment. (Those who don't is a different story of course). 

After all, unlike other opiates, Heroins only negative effect/side effect is resp and neurological depression. It does not damage organs of tissues, does not accumulate, is not toxic persay and if you' ve largley reversed the main effects then what is clinically wrong with the pt that requires mandatory ED assessment? The docs at most will give more Narcan and discharge the pt -that's it. 

MM


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## firetender (Jul 19, 2011)

MrBrown said:


> Anybody who feels it necessary to prophylactically restrain an overdose patient before waking them up is a piss poor ambo who should be forever banned from practising


 
I agree wholeheartedly, unless, of course, it's the second time in that hour, the first time having been a violent response and forceful exit out into the streets. (You can fill in the blank with your own scenario.)

 A couple of choices here; call the cops and for sure have far less gentle restraint imposed, or wait for the patient to lose consciousness, respond, protect the crew AND the patient by restraint and THEN administer the drug that brings him back. There are probably more, as well.

Brown, you know better than most that there are so many variables in the biz, it doesn't really pay to make blanket statements about fitness to serve. And, no, I didn't take your statement personally, I just get in hackles about summary judgments amongst ourselves. Don't we get that enough from everybody else?


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## JeffDHMC (Jul 19, 2011)

Melbourne MICA said:


> Ditto both these comments.
> 
> 
> I've never seen a "scoop sandwich" but it sounds postitively medieaval.
> ...



Yeah, it was bad. Never used for H ODs, but for the unmanageable combative pt BITD before droperidol or versed. I'm glad that kind of stuff is long gone.

Jeff


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## systemet (Jul 21, 2011)

Some interesting points being made here.

* We used to give narcan IV slowly in 0.4mg increments, or 0.8mg IM.  We were encouraged to transport all ODs, and discouraged from cancelling, in case the patient had overdosed on something with a longer half-life than narcan.

* Our goal was always to alleviate respiratory depression and avoid advanced airway management in selected opiate overdoses.  Waking someone to a GCS 15 and potentially combative was to be avoided, if possibly.  Good ventilation / oxygenation prior to narcan was emphasised.  If we were uncertain as to polypharmacy, we were told to intubate and transport.

I think this strategy worked well for us, because we had relatively few heroin users in our city.  We saw a lot of IV cocaine, crack, methamphetamine, but relatively few opiate ODs.  As a result, our ERs weren't overwhelmed by transported opiate ODs.  We didn't have a pressure to keep them out of the ERs.  We also had community narcan, where local users could get trained to administer a narcan preload.  I'm not sure how big of an impact this made, but there were certainly people being woken up without 911 being called (the protocol was to call 911, but I'm sure a lot of people weren't compliant).  

I think when you have cities where heroin usage is more prevalent, your chance of having a pure opiate OD is probably greater, and the incentive to treat and release is higher.  I wonder if this is also sometimes tied into healthcare economics?  It seems that heroin users wouldn't be a particularly billable segment of society.  

* We were advised to place the patient in soft restraints before administering narcan, even though we were using small doses.  I'm suprised to see such strong reactions against doing this.  This wasn't an attempt to be punitive towards the patient, it was just done on the basis that if someone woke up too fast, or remained confused, that they might decide to fight, especially if they thought we were the police.

I've never really considered that practice in the context of waking up diabetics.  It seems like there's an assumption that a diabetic is less likely to come up swinging.  Based on personal experience with D50W, it seems like these patients wake up slower than someone given a large dose of narcan.  I've had more problem with them being aggressive at that point between being hypoglycemic and unconscious.  That's when glucagon was a good option, in my mind.

* I think the scoop sandwich was useful as a form of restraint in times when chemical restraint wasn't available.  But I also think it was barbaric, and is best relegated to the same box of tricks with supine restraint.  IV (or IM) benzodiazepines are safer for the patient, more legally defensible, and less likely to result in injury.  They also solve the problem of how the patient comes off the stretcher once we're at the hospital.

All the best.


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