# Naloxone Admin By EMT's



## HWhite98 (Jul 20, 2015)

So recently my local protocols were updated to allow the administration of naloxone (Narcan) by EMT basics via nebulizer. My question to all of you is what is your opinion on this matter? Should EMTs be able to give patients Narcan? For my fellow basics out there, are you authorized to administer Narcan?

I live in VA btw.


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## Flying (Jul 20, 2015)

In NJ, this varies agency to agency depending on the medical director. I lean towards EMTs having the option of IN narcan.

We suck at ventilation and it adds value to EMTs in rural systems.


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## ERDoc (Jul 20, 2015)

If we can teach families and addicts how to give it, why can't EMTs give it?  Sure, no medicine is without side effects but more are better than not breathing and dead.


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## RedAirplane (Jul 20, 2015)

ERDoc said:


> If we can teach families and addicts how to give it, why can't EMTs give it?  Sure, no medicine is without side effects but more are better than not breathing and dead.



Addicts give Narcan to themselves after they are unconscious? Huh?

Family members makes more sense and I just Googled it. Looks like a good idea.


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## Flying (Jul 20, 2015)

RedAirplane said:


> Addicts give Narcan to themselves after they are unconscious? Huh?


Addicts make contact with other addicts. One can help the other.


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## Tigger (Jul 20, 2015)

Just by the way, you are using an atomizer and not a nebulizer.

Had in MA where I started (the police had it way before us), and I have it here in Colorado both IN and IV. I think it has a place considering how poorly many EMS providers use a BVM. A solid education program is important to teach when and when it's not appropriate to give as well as what should be given dose wise (maybe not every patient needs a full two milligrams).


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## HWhite98 (Jul 20, 2015)

Good comments so far. I have heard that some PD's have officers carry and administer as well, although none around here do.


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## Chewy20 (Jul 20, 2015)

Had it in MA as well. Used it once. She stayed dead.


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## Gurby (Jul 20, 2015)

I'm in MA... PD, FD and BLS all have it.  Seems ludicrous to me for BLS to not have it!


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## medichopeful (Jul 20, 2015)

HWhite98 said:


> So recently my local protocols were updated to allow the administration of naloxone (Narcan) by EMT basics via nebulizer. My question to all of you is what is your opinion on this matter? Should EMTs be able to give patients Narcan? For my fellow basics out there, are you authorized to administer Narcan?
> 
> I live in VA btw.



I carry it when I'm working on the ambulance, have given it myself a few times, and have been on scenes where others have given it IN (via an atomizer, not a nebulizer.  A nebulizer is a bit different just so you know ).  Overall, I'd say it's a good idea.

The problem, however, is training.  Many people believe that opiate use automatically buys narcan.  If the patient is talking to you or you have to tell them to "hold still," odds are they don't need it (and yes, I know of at least one case where it was given to a perfectly conscious patient).  If trained correctly, EMTs SHOULD be able to carry it and use it.  It's a medication that truly saves lives.

It just needs to be remembered that the point of narcan pre-hospitably shouldn't be to ruin a high or wake the person up.  Instead, it should be to maintain an adequate respiratory drive.  Aim for breathing, not consciousness.


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## NomadicMedic (Jul 20, 2015)

Absolutely appropriate for BLS. 

Just before leaving DE I was dispatched to an arrest. BLS arrived before me. (I was a single medic in a suburban). They advised via radio that it looked like an opiate OD and were giving Narcan and assisting ventilation. A few minutes later, "patient is conscious and breathing". 

Whew. No code for me. (Which was good, it was close to quitting time!) 

That's when it should be used.


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## Carlos Danger (Jul 20, 2015)

The only problem I see with BLS naloxone is potential over-use. I can envision it very frequently being given in cases of reduced LOC that are unrelated to opioid use.

Find a way to get a handle on that, and it's all good.


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## CALEMT (Jul 20, 2015)

HWhite98 said:


> For my fellow basics out there, are you authorized to administer Narcan?



In Southern California thats a big fat hell no! For the most part theres a medic on scene (fire or ambulance). In my county fire has at least 1 medic on the engine and 1 medic with 1 EMT on the ambulance. BLS won't respond to 911 calls unless were lvl 0 (no ALS rigs) and that almost never happens. Would it be nice to administer Narcan as a EMT? Hell yeah! Is it practical to administer Narcan as a EMT? Hell no.


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## ffemt8978 (Jul 20, 2015)

medichopeful said:


> It just needs to be remembered that the point of narcan pre-hospitably shouldn't be to ruin a high or wake the person up.  Instead, it should be to maintain an adequate respiratory drive.  *Aim for breathing, not consciousness*.



Emphasized for the truth....the last thing you want is a patient waking up with a ruined high in the back of an ambulance.  Nor is it a good idea to slam Narcan as your wheeling the patient thru the ER doors.


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## Tigger (Jul 20, 2015)

CALEMT said:


> In Southern California thats a big fat hell no! For the most part theres a medic on scene (fire or ambulance). In my county fire has at least 1 medic on the engine and 1 medic with 1 EMT on the ambulance. BLS won't respond to 911 calls unless were lvl 0 (no ALS rigs) and that almost never happens. Would it be nice to administer Narcan as a EMT? Hell yeah! Is it practical to administer Narcan as a EMT? Hell no.


Why is it not practical?


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## CALEMT (Jul 20, 2015)

Tigger said:


> Why is it not practical?



You have a medic on every 911 call wether its fire or ambulance. The only way a EMT would give Narcan would be a still alarm, or they responded to a 911 call. I meant it wouldn't be practical in the sense of stocking it on the BLS ambulances.


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## Tigger (Jul 20, 2015)

Ah. Here it is commonplace for the EMTs to give the medications in their scope even with having a medic onboard every ambulance.


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## CALEMT (Jul 20, 2015)

Tigger said:


> Ah. Here it is commonplace for the EMTs to give the medications in their scope even with having a medic onboard every ambulance.



It would make more sense for the rural counties in CA i.e. Tulare, Tuolumne, Mariposa that have BLS 911 rigs but for more larger counties like Riverside, San Bernardino, San Diego that have ALS 911 rigs its not practical.


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## Tigger (Jul 21, 2015)

CALEMT said:


> It would make more sense for the rural counties in CA i.e. Tulare, Tuolumne, Mariposa that have BLS 911 rigs but for more larger counties like Riverside, San Bernardino, San Diego that have ALS 911 rigs its not practical.


We don't really do BLS 911 ambulances out here (certainly not paid). I work for a pretty rural place with P/B ambulances where the EMTs have a legitimate scope of practice (for their education) and can take their own patients. While many post overdose patients need an ALS attend, not all of them do so those patients end up being my attend.


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## TransportJockey (Jul 21, 2015)

NM basics have been allowed to give Narcan IN/IM/SQ for a long time. It's not had any adverse effects that I'm aware of


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## Jim37F (Jul 21, 2015)

Also don't forget that EMT includes FF/EMT, not just private ambulance guys, so if the first in engine is all EMTs waiting on the medics coming in from out of district (not terribly uncommon here), even L.A. Co might eventually see the logic of making Narcan a BLS skill (then again we barely just got pulse ox monitoring a year or so ago and no consideration given to allowing us to do a test people do every day with an Over The Counter kit from the local CVS....So I wouldn't hold my breath lol)


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## HWhite98 (Jul 21, 2015)

I haven't personally given Narcan to a patient, mainly since I am new to the trade (Just found out today the state "officially" put my cert through ) but I have been to one overdose where a BLS provider was first on the scene in a rapid response vehicle and had given it. I guess it ultimately depends on location, and availability of ALS providers.


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## chaz90 (Jul 21, 2015)

Delaware started a pilot program for BLS administration of Narcan a couple months ago. The governor authorized LE across the state to carry it, so the powers that be decided that should probably open it up to BLS as well. They carry a MAD and can only administer it through the atomizer. I haven't seen it administered by BLS when I've been working yet, but I know a few have. They're very careful to emphasize that it should only be administered prehospitally to regain an effective respiratory drive. We, as the county ALS service, are typically only a couple minutes behind BLS, but there are cases where we're significantly delayed for some reason or it was initially a BLS dispatch. In those cases, I'm all for it.


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## CALEMT (Jul 21, 2015)

chaz90 said:


> The governor authorized LE across the state to carry it



Ive seen a couple posts on this thread about LE carrying and administering Narcan. Do they have to be a certified EMT? First Responder? or is it just a class/ training that they take?


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## chaz90 (Jul 21, 2015)

CALEMT said:


> Ive seen a couple posts on this thread about LE carrying and administering Narcan. Do they have to be a certified EMT? First Responder? or is it just a class/ training that they take?


Separate class here. Some are EMRs or EMTs, but it's not required. As was mentioned earlier, it's gradually becoming more available OTC even to laypeople.


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## CALEMT (Jul 21, 2015)

Interesting.


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## HWhite98 (Jul 21, 2015)

CALEMT said:


> Ive seen a couple posts on this thread about LE carrying and administering Narcan. Do they have to be a certified EMT? First Responder? or is it just a class/ training that they take?



My local PD all of their officers are EMR's, however not all departments are like this. They do have training classes on the administration of Narcan.


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## Bullets (Jul 21, 2015)

I hate it, i hate that NJ did what they did with it, and i hate the way the state DOH wrote the EMT policy regulating it. (2mg IN....thats it)

Thankfully we dont carry it on our trucks, but weve carried an opiate reversal for years, the BVM. While i admit that EMS is pretty terrible in using the BVM, the solution to that isnt giving us a drug and making us take a class on its use. Maybe a 4 hour class on airway/ventilation would be more productive.


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## Flying (Jul 21, 2015)

What do you feel has gone wrong with the way Narcan has been implemented?

2 mg seems to be an effective dose for EMTs to have, and our goal should be to treat the cause of respiratory depression in these patients while supporting with good ventilation. The 4 hour class that you advocate would probably teach this as well.



Edit: Wait a sec, just four hours? I don't need another beer and chuckle session, lets make that an actual class.


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## rwik123 (Jul 21, 2015)

PD and BLS have it in my neck of the woods. BLS has the straight 2mg and cannot titrate. In regards to indication, I've even seen fellow ALS providers give it to patients who don't need to be receiving it. Unconscious+solid respiratory effort will never get narcan from me.


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## Gurby (Jul 22, 2015)

Bullets said:


> I hate it, i hate that NJ did what they did with it, and i hate the way the state DOH wrote the EMT policy regulating it. (2mg IN....thats it)
> 
> Thankfully we dont carry it on our trucks, but weve carried an opiate reversal for years, the BVM. While i admit that EMS is pretty terrible in using the BVM, the solution to that isnt giving us a drug and making us take a class on its use. Maybe a 4 hour class on airway/ventilation would be more productive.



Sarcasm is hard to detect on the internet - you're joking right?


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## Carlos Danger (Jul 22, 2015)

Bullets said:


> I hate it, i hate that NJ did what they did with it, and i hate the way the state DOH wrote the EMT policy regulating it. (2mg IN....thats it)
> 
> Thankfully we dont carry it on our trucks, but weve carried an opiate reversal for years, the BVM. While i admit that EMS is pretty terrible in using the BVM, the solution to that isnt giving us a drug and making us take a class on its use. *Maybe a 4 hour class on airway/ventilation would be more productive.*



I have never understood all the people who say "we don't need no stinkin' narcan - we should just ventilate." I think that completely misses the point.

If a 4-hour class were all it took to go from being "pretty terrible" to competent, then methinks we'd already have it covered.


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## ThadeusJ (Jul 22, 2015)

I believe VA was investigating the administration of Narcan using a standard small volume neb and mask a few years ago.  The reason for this approach was that it allows you to stop the treatment once effect has been reached.  This is in comparison to nasal atomizers and IV administration where the dose is given and you hope you don't overshoot your goal.  This approach might be seen as safer and therefore more appropriate for BLS crews.  I believe the nasal atomizer approach is more cost effective as well.


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## chaz90 (Jul 22, 2015)

ThadeusJ said:


> I believe VA was investigating the administration of Narcan using a standard small volume neb and mask a few years ago.  The reason for this approach was that it allows you to stop the treatment once effect has been reached.  This is in comparison to nasal atomizers and IV administration where the dose is given and you hope you don't overshoot your goal.  This approach might be seen as safer and therefore more appropriate for BLS crews.  I believe the nasal atomizer approach is more cost effective as well.


So you use PPV with the inline neb mask to get it into the lungs? This seems inefficient and cumbersome when the medication is meant to be administered to unconscious and apneic patients. IM/IN seems easy and safe to me.


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## Bullets (Jul 22, 2015)

Flying said:


> What do you feel has gone wrong with the way Narcan has been implemented?
> 
> 2 mg seems to be an effective dose for EMTs to have, and our goal should be to treat the cause of respiratory depression in these patients while supporting with good ventilation. The 4 hour class that you advocate would probably teach this as well.
> 
> ...


2mg flat dose is not appropriate. We should be allowed to tiitrate the dose for effect, instead of giving everyone a dose they may not need



Gurby said:


> Sarcasm is hard to detect on the internet - you're joking right?


Dead serious, i dont like narcan and i have issues with the way it came about and how its used. 


Remi said:


> I have never understood all the people who say "we don't need no stinkin' narcan - we should just ventilate." I think that completely misses the point.
> 
> If a 4-hour class were all it took to go from being "pretty terrible" to competent, then methinks we'd already have it covered.



If ventilation is sufficient to revive these patients, why give drugs front line? Dont we use vagal maneuvers before we go to meds? Meds before electricity? Just levels of treatment

Im not saying 4 hours is all it takes, currently the class the state has rolled out to LEO/EMS agencies who are looking to carry Narcan is 4 hours. I feel if you are going to only give 4 hours to treating this, the focus should be on proper ventilation and BVM use.


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## Carlos Danger (Jul 22, 2015)

Bullets said:


> 2mg flat dose is not appropriate. We should be allowed to tiitrate the dose for effect, instead of giving everyone a dose they may not need
> 
> 
> Dead serious, i dont like narcan and i have issues with the way it came about and how its used.
> ...



First, 2 mg is a perfectly appropriate dose - especially IN, with such unpredictable absorption anyway - if the choice is between that and allowing the patient to continue hypoventilating. It is not appropriate to expect EMT's and cops to "titrate" medication doses in a critical patient.

Second, opioid overdose is a life-threatening toxidrome with sequelae that includes more than just hypoventilation, and it can be easily and reliably and safely reversed with the administration of a single antidote. That's why you give it "front line".

Lastly, you already admitted in an earlier post that "EMS is pretty terrible at BVM ventilation", yet you keep insisting that our primary approach to managing these critical patients should be BVM ventilation? Uh.....OK.

My whole career I've heard people say what a bad drug naloxone is. Those people simply don't know what they are talking about.


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## Flying (Jul 22, 2015)

Out of many, I know very few EMTs who have even heard of titration. The flat dose is there for a reason.

Having greater control over the dosage would be great, but we must design the system considering what we have, not what we want.


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## medichopeful (Jul 23, 2015)

Any system should be able to put basic titration into effect. The way we do it where I work is one 1mg up a nare, then wait. If another dose is needed, we give it up the other nare.


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## DesertMedic66 (Jul 23, 2015)

Welcome to my county where the only thing medics are allowed to titrate without a base order is oxygen. Everything else we have to call.


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## Carlos Danger (Jul 23, 2015)

medichopeful said:


> Any system should be able to put basic titration into effect. The way we do it where I work is one 1mg up a nare, then wait. If another dose is needed, we give it up the other nare.



How long do you wait before giving the second dose?

That's great if you can manage the airway while waiting to see if the first mg is going to work. But do we really want cops and EMT's who don't know how to manage the airway waiting to see if the patient is going to start breathing before deciding whether to give the second dose?


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## ThadeusJ (Jul 23, 2015)

@chaz90: not PPV ventilation, just a standard mask (versus the T-pce style neb) and a neb, just like albutarol.  Mind you, in respiratory circles they commonly use vents to administer aerosolized medications.  Its called IPPB.  No one really uses it in Canada but its big in the US.


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## chaz90 (Jul 23, 2015)

ThadeusJ said:


> @chaz90: not PPV ventilation, just a standard mask (versus the T-pce style neb) and a neb, just like albutarol.  Mind you, in respiratory circles they commonly use vents to administer aerosolized medications.  Its called IPPB.  No one really uses it in Canada but its big in the US.


Right, but how does that work if the patient is apneic if you're not actually ventilating? I feel like I'm missing something here, so perhaps my tired brain just isn't operating properly.


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## ThadeusJ (Jul 23, 2015)

If apnea is involved it won't work and the situation is more serious.  In that situation it would be very hard to titrate and the IV route or nasal aerosol would be the only options.  I suppose you could intubate and use a neb hooked into the vent circuit until spontaneous resps and other vitals come back but thats getting tricky perhaps straying a bit too far from conventional treatment.  And that's only to prevent the patient from waking up too fast and leaving before the performance is over.


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## jwk (Jul 29, 2015)

Bullets said:


> 2mg flat dose is not appropriate. We should be allowed to tiitrate the dose for effect, instead of giving everyone a dose they may not need
> 
> 
> Dead serious, i dont like narcan and i have issues with the way it came about and how its used.
> ...



I think you totally miss the point of having IN narcan in the hands of basic EMT's or cops.  There are NUMEROUS reports of saves by LE who are first on the scene with an OD.  They aren't going to have good (if any) airway skills.  For that matter, most non-anesthesia folks have horrible BVM skills, and you certainly won't learn that in a four hour class.  However, a good four hour class for using IN narcan is going to be a cheap way to save some lives - it already has.  They're on the news when their department gets it and on the news when they have a save.

Ventilation in a narcotic OD does NOT revive apneic or near-apneic patients.  They are not going to wake up just because you're ventilating them.  You need to think about that statement again.  If they do, then narcotic OD wasn't their problem to begin with.

Do we use "meds before electricity"?  Hmmmmm.  Think about that statement again as well and perhaps go back and review your ACLS.

Not sure how long you've been doing this, but I suspect narcan has been around a lot longer than you, so I'm not sure how you can have a problem with the way it came about, and considering it's success, I'm not sure how you can have a problem with how it's used - except that you're getting beat to the punch on a save by a cop with a four hour narcan course.  IMHO


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## Bullets (Jul 31, 2015)

jwk said:


> I think you totally miss the point of having IN narcan in the hands of basic EMT's or cops.  There are NUMEROUS reports of saves by LE who are first on the scene with an OD.  They aren't going to have good (if any) airway skills.  For that matter, most non-anesthesia folks have horrible BVM skills, and you certainly won't learn that in a four hour class.  However, a good four hour class for using IN narcan is going to be a cheap way to save some lives - it already has.  They're on the news when their department gets it and on the news when they have a save.
> 
> Ventilation in a narcotic OD does NOT revive apneic or near-apneic patients.  They are not going to wake up just because you're ventilating them.  You need to think about that statement again.  If they do, then narcotic OD wasn't their problem to begin with.
> 
> ...


NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.

There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success


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## Bullets (Jul 31, 2015)

double post


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## Chewy20 (Jul 31, 2015)

Bullets said:


> NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.
> 
> There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success



Then we should also stop doing CPR, because more often then not the outcome is grim? They should make it public. It is in the interest of everyone, why not have a good story on the news, ESPECIALLY with all the crap PDs are putting up with now-a-days?

It sounds like you are a little mad that PDs have the same scope of practice as you in a backward state for EMS. All on the same team, who cares who gets the "save".


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## Carlos Danger (Aug 1, 2015)

Bullets said:


> NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.



"Slammed through"? So what? It's easy. Person not breathing = suspect opioid involvment = give nalaxone. It's not rocket science.

I agree that being able to use nalaxone but not a glucometer is dumb. So get things changed to allow use of a glucometer.



Bullets said:


> There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success



Yes, this is what public safety agencies do.....they toot their own horn as loudly as possible at any opportunity for publicity. I find it rather off-putting as well.

But that has absolutely nothing to do with the clinical question of whether cops should be using naloxone. A save is a save. If cops are getting these people breathing again before EMS arrives......how do you possibly justify being against that?


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## Summit (Aug 1, 2015)

Just a thought... if we can't trust these cops and EMTs to provide rescue breaths or BVM, then they shouldn't have those skills or should be further trained.

IF you cannot trust their airway skills for short duration assisted ventilation, how can you expect them to deal with other airway issues like a common side effect of giving 2mg of naloxone: emesis. (which is why titration is desirable)

I bet they call it a save even if the patient ends up dying of ARDS in the ICU s/p aspiration pneumonia. I don't have data on the prevalence of these complications for lay and BLS administered naxolone but it would be an interesting study.


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## Jim37F (Aug 1, 2015)

Isn't a solution that actually solves the problem of why that particular patient isn't breathing and gets the patient breathing again better than one that doesn't? 

After all, you're not gonna argue that cops and BLS should only manually pump the heart instead of using a proven intervention to restart it (AED) are you?


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## chaz90 (Aug 1, 2015)

Summit said:


> Just a thought... if we can't trust these cops and EMTs to provide rescue breaths or BVM, then they shouldn't have those skills or should be further trained.
> 
> IF you cannot trust their airway skills for short duration assisted ventilation, how can you expect them to deal with other airway issues like a common side effect of giving 2mg of naloxone: emesis. (which is why titration is desirable)
> 
> I bet they call it a save even if the patient ends up dying of ARDS in the ICU s/p aspiration pneumonia. I don't have data on the prevalence of these complications for lay and BLS administered naxolone but it would be an interesting study.


Isn't the possibility of aspiration preferable to the larger risk of death if LE comes across an apneic and severely hypoxic opioid OD and EMS is still some distance away? Teaching LEO/medical laypeople to administer 2 mg IN Naloxone then roll the patient to their side sounds to me to be an appropriate treatment with a high reward and relatively low risk. Aspiration pneumonia is also of course a possibility after poor or prolonged attempts at utilizing a BVM with poor techniques and hyperventilation. More training and emphasis on proper use of the BVM for the entire EMS community is a worthy goal, but perhaps not the same issue as increased access to Naloxone. 

In most areas I imagine that some variety of first response or transport capable EMS (at least at the BLS level) should be pretty close behind LE entering these scenes. With that in mind, I could certainly get behind the argument that simply equipping first response or BLS units with Narcan could be a positive first step. Even if their ability to utilize a BVM may not be 100% perfect (or let's be real, possibly completely inadequate), they do at least have some understanding of basic airway management and suction devices available. I can't say I see too many people begin profusely vomiting after IN Narcan either, and they certainly do a better job oxygenating themselves with return of spontaneous resps than I usually see with the initial attempts at using a BVM. 

I think this has the potential to save lives. We talk about the importance of bystander CPR and public access AEDs, which I completely support of course, but I see way more potentially viable opioid ODs than I do witnessed cardiac arrests.


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## Carlos Danger (Aug 1, 2015)

Summit said:


> Just a thought... if we can't trust these cops and EMTs to provide rescue breaths or BVM, then they shouldn't have those skills or should be further trained.
> 
> IF you cannot trust their airway skills for short duration assisted ventilation, how can you expect them to deal with other airway issues like a common side effect of giving 2mg of naloxone: emesis. (which is why titration is desirable)
> 
> I bet they call it a save even if the patient ends up dying of ARDS in the ICU s/p aspiration pneumonia. I don't have data on the prevalence of these complications for lay and BLS administered naxolone but it would be an interesting study.



So what are the options here?

1. Cop gives narcan, takes a chance that it causes emesis or another bad side effect.

2. Cop does lousy airway management with a BVM, ventilates the lungs poorly, insuflates the gut, takes a chance that it causes emesis or another bad side effect.

3. Cop does nothing but stand by and call on the radio asking EMS to "expedite".

Number 3 is the status quo, and number 2 is what is most likely to happen if you try to train these guys to use a BVM - even a modicum of proficiency with airway management is never going to happen.


Nalaxone administration does include risks, especially at higher doses. Hypertension, tachycardia, and nausea, among others. However.......I don't think any of those are as hazardous to one's health as apnea.


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## Summit (Aug 1, 2015)

I am in favor of BLS and even lay rescuers having naloxone.

Rereading my post, I didn't communicate clearly. 

What I have a problem with is the writing off of airway management for anyone below Paramedic! The lack of focus on this critical skill is atrocious.


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## Carlos Danger (Aug 1, 2015)

Summit said:


> I am in favor of BLS and even lay rescuers having naloxone.
> 
> Rereading my post, I didn't communicate clearly.
> 
> What I have a problem with is the writing off of airway management for anyone below Paramedic! The lack of focus on this critical skill is atrocious.



I definitely agree.....but the reality is that it takes more practice to master BVM ventilation than most EMS programs and agencies (and certainly police departments) are going to invest in.

My opinion is drifting towards more liberal use of SGA's by BLS in lieu of BVM management.


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## EpiEMS (Aug 2, 2015)

Remi said:


> I definitely agree.....but the reality is that it takes more practice to master BVM ventilation than most EMS programs and agencies (and certainly police departments) are going to invest in.
> 
> My opinion is drifting towards more liberal use of SGA's by BLS in lieu of BVM management.



Could you expand on the latter point? Why would more liberal use of SGAs be _in lieu of_ BVMs?


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## Carlos Danger (Aug 2, 2015)

EpiEMS said:


> Could you expand on the latter point? Why would more liberal use of SGAs be _in lieu of_ BVMs?



I just mean I we clearly need an alternative to BVM ventilation for BLS providers.


----------



## Aprz (Aug 2, 2015)

I just read the last few posts only. I think Remi is saying that people are usually poor at getting a good seal with a bag valve mask so he thinks it might be better to consider using a supraglottic airway more frequently so you don't have to worry about getting a good seal. When he says using a BVM, he means bag-mask ventilation. You are still going to use a bag valve mask to ventilate via the supraglottic airway rather than the mask being applied to the face.


----------



## Gurby (Aug 2, 2015)

EpiEMS said:


> Could you expand on the latter point? Why would more liberal use of SGAs be _in lieu of_ BVMs?



Much easier to learn how to pop in a SGA than to teach someone to create a good seal with a BVM.  Even after 40 hours in the OR I'm still trash with the BVM, but putting in LMA's is no problem after doing it a couple times.


----------



## NomadicMedic (Aug 2, 2015)

^^truth. An SGA should be the airway of choice for an arrest, both BLS and ALS.


----------



## EpiEMS (Aug 2, 2015)

Makes sense to me, just wanted to clarify. Thanks!


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## jlicp112 (Aug 7, 2015)

It's a recent skill here for both EMT's and EMR's simply because it's given out like candy to the public anyway and not having it wouldn't make sense


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## RobertAlfanoNJEMT (Sep 3, 2015)

I think they should be able to use it... If its just me alone in the back of the ambulance and I'm 20 or 30 mins out I'm not gonna do it because I'm not going to put myself in danger if they become combative when they wake up.. But if the EMT feels comfortable and has some extra hands when they wake up I say go for it.. it can't do anything but help your patient


----------



## Chewy20 (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I think they should be able to use it... If its just me alone in the back of the ambulance and I'm 20 or 30 mins out I'm not gonna do it because I'm not going to put myself in danger if they become combative when they wake up.. But if the EMT feels comfortable and has some extra hands when they wake up I say go for it.. it can't do anything but help your patient



So you're not going to provide a potentially life-saving intervention because you are afraid of being hit? Are you kidding me? Tie the guy to the stretcher. Or better yet give it to the dude on scene and wait for him to come around while your partner is still with you.

Maybe I havent seen enough narcan given, but every time they snap out of it, its not the schools definition of "they are basically the devil being woken up, and you better watch out."


----------



## NomadicMedic (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I think they should be able to use it... If its just me alone in the back of the ambulance and I'm 20 or 30 mins out I'm not gonna do it because I'm not going to put myself in danger if they become combative when they wake up.. But if the EMT feels comfortable and has some extra hands when they wake up I say go for it.. it can't do anything but help your patient



This is ridiculous. 

How about "do your job"?


----------



## triemal04 (Sep 3, 2015)

DEmedic said:


> This is ridiculous.
> 
> How about "do your job"?


Psssst!  He's from Jersey!  

I kid, I kid...

In all seriousness, that is the worst excuse ever, though I've no doubt many people have said it, and likely DONE IT.

Maybe, "learn how to do your job" and then "do your job."


----------



## CALEMT (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I think they should be able to use it... If its just me alone in the back of the ambulance and I'm 20 or 30 mins out I'm not gonna do it because I'm not going to put myself in danger if they become combative when they wake up.. But if the EMT feels comfortable and has some extra hands when they wake up I say go for it.. it can't do anything but help your patient



Ummm what? Thats like saying I'm not going to do CPR because I'm afraid I'm going to break the persons ribs. Like Chewy says break out the 4 points and if you feel like thats not enough break out the d rings and tie him to the gurney.

Every time I've seen narcan given the patient hasn't been fight to the death incredible hulk. Sure they'll be a bit rowdy, but thats because you just took them off their high.


----------



## medichopeful (Sep 3, 2015)

Chewy20 said:


> Maybe I havent seen enough narcan given, but every time they snap out of it, its not the schools definition of "they are basically the devil being woken up, and you better watch out."



I may have had one person who was a bit violent, but this was a while ago and I can't honestly remember if he was violent, or disoriented, or totally fine and I'm just not remembering it correctly.  That being said, I've seen it given or given it multiple times, and besides being a bit upset, I can't think of many people (if any) that have been violent when they're woken up.  Moral of the story, I agree with you that the school's definition of the devil is pretty ridiculous.

That being said, I think that violence is possible, but only if it's administered incorrectly.  For example, IV slam.  Correctly administered, the concern over violence is pretty bogus IMHO.


----------



## medichopeful (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I think they should be able to use it... If its just me alone in the back of the ambulance and I'm 20 or 30 mins out I'm not gonna do it because I'm not going to put myself in danger if they become combative when they wake up.. But if the EMT feels comfortable and has some extra hands when they wake up I say go for it.. it can't do anything but help your patient



The goal of narcan isn't to wake the patient up.


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## ViolynEMT (Sep 3, 2015)

The only "bad" reaction from a patient waking up that I've experienced is getting puked on. All part of the job. That's what laundry detergent is for.


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## RobertAlfanoNJEMT (Sep 3, 2015)

I'm responsible for helping myself and keeping myself safe before my patient.. I'm just considering that delivering this drug can make the scene unsafe and if it's unsafe then no one is being helped! You can't resrain your patient either.. That's how you get charged for battery.. I never said I wouldn't use it I just said I would be considering what could happen if I did use it


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## teedubbyaw (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I'm responsible for helping myself and keeping myself safe before my patient.. I'm just considering that delivering this drug can make the scene unsafe and if it's unsafe then no one is being helped! You can't resrain your patient either.. That's how you get charged for battery.. I never said I wouldn't use it I just said I would be considering what could happen if I did use it



What the hell are you talking about?


----------



## RobertAlfanoNJEMT (Sep 3, 2015)

teedubbyaw said:


> What the hell are you talking about?


Applying to which part?


----------



## teedubbyaw (Sep 3, 2015)

So far, everything.


----------



## RobertAlfanoNJEMT (Sep 3, 2015)

teedubbyaw said:


> So far, everything.


Well when you have a legitament specific question let me know


----------



## teedubbyaw (Sep 3, 2015)

OK.

What is narcan? Why do we give it/what do we titrate it to?

Why is restraining a patient "battery" if it's for you and your pt's safety?


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## RobertAlfanoNJEMT (Sep 3, 2015)

Narcan is a drug administered when you believe a patient is in a drug overdose... In New Jersey we do not titrate it.. We are only given permission to give it intro nasally at a BLS level.. And I'm not saying I personally believe it is battery to restrain your patient but you may very well end up in court having to explain yourself if your patient believes you were abusing them and restraining them


----------



## teedubbyaw (Sep 3, 2015)

Like someone said, narcan isn't given to 'wake someone up.' Opioid drugs decrease respiratory drive. Narcan 'reverses' the effects of opioids. Breathing pt = good pt. We do not withhold narcan because a pt may become combative. That is negligence. Negligence will get you into trouble long before restraining a substance abuser (or accidental OD) for the purpose of their and your safety.


----------



## Jim37F (Sep 3, 2015)

I guess that's why always hear about cops getting charged for battery by restraining individuals during investigations....

Either you have the world's worst EMS restraints policy or you're so afraid of "my old partners buddy's next door neighbor once knew a Paramedic who got taken to court for this" you're afraid to actually do your job.


----------



## Flying (Sep 3, 2015)

RobertAlfanoNJEMT said:


> And I'm not saying I personally believe it is battery to restrain your patient but you may very well end up in court having to explain yourself if your patient believes you were abusing them and restraining them


Whomever you heard that from, ignore them from now on. That is bollocks.

You talk about putting your safety first, yet don't advocate for the use of restraints? Restraints aren't abuse, we have the option of tying people manually and using chemical restraints. Both are ethical and legally defensible in the case of securing the patient's and your own safety.


----------



## CALEMT (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I'm responsible for helping myself and keeping myself safe before my patient.. I'm just considering that delivering this drug can make the scene unsafe and if it's unsafe then no one is being helped! You can't resrain your patient either.. That's how you get charged for battery.. I never said I wouldn't use it I just said I would be considering what could happen if I did use it



The ignorance is strong with this one. Teedubb explained it perfectly, if you withhold treatment from someone that needs it well thats textbook negligence. 

Also restraints as battery? Thats a first for me. If you feel the pt is a danger to himself, you, or others then he/she needs to be restrained. Ive used everything from the 4 point "soft" restraints on the gurney to d rings and 4 points. Whatever you have to do to make your scene and patient safe. In my honest opinion I think you're afraid of all this legal crap you learn in school and its affecting the way you provide care. Withholding treatment in fear of a scene _*potentially*_ becoming violent just absolutely blows my mind and is negligence.


----------



## Chewy20 (Sep 3, 2015)

RobertAlfanoNJEMT said:


> I'm responsible for helping myself and keeping myself safe before my patient.. I'm just considering that delivering this drug can make the scene unsafe and if it's unsafe then no one is being helped! You can't resrain your patient either.. That's how you get charged for battery.. I never said I wouldn't use it I just said I would be considering what could happen if I did use it



HAHAH you are gonna be one heck of a provider. 

Now that's out of my system. First of all, narcan isn't to wake someone up so you can get their info. It's a intervention to stop the OPIOID (not any drug) process and get respiratory drive back (what's a common thing in opioid use?). Second of all, you are taught how to restrain someone in class. Hence its not battery. I would laugh in my way to a court room if that's what I was going for. 

So next question. Will you never give any type of med? They all can have adverse effects. Mine as well not give them just incase...

Take that school mentality of "scene safety/BSI or die" crap and throw it out the window. Learn how to use your brain.


----------



## teedubbyaw (Sep 3, 2015)

Says he's a student, so don't be too hard on him...unless he's employed in a 911 system.


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## NomadicMedic (Sep 3, 2015)

Maybe another reason we need to provide more education to BLS than, "squirt it up their nose then look out".


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## Chewy20 (Sep 3, 2015)

teedubbyaw said:


> Says he's a student, so don't be too hard on him...unless he's employed in a 911 system.



He's not asking questions. He's making statements, so he has already been taught the subjects. Either he didn't pay attention, he can't comprehend, instructor is bad or he doesn't take the extra step to learn more. Either way, no Bueno.


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## RobertAlfanoNJEMT (Sep 3, 2015)

Chewy20 said:


> He's not asking questions. He's making statements, so he has already been taught the subjects. Either he didn't pay attention, he can't comprehend, instructor is bad or he doesn't take the extra step to learn more. Either way, no Bueno.


I've already graduated the academy and am just waiting on my test score for the nj state test..


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## Chewy20 (Sep 4, 2015)

RobertAlfanoNJEMT said:


> I've already graduated the academy and am just waiting on my test score for the nj state test..



Further proving my point that you are not ready to be in the streets...


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## RobertAlfanoNJEMT (Sep 4, 2015)

Chewy20 said:


> Further proving my point that you are not ready to be in the streets...


Actually the next step is to be in the streets.. There is no more learning.. It's time to gain experience by actually caring for patients


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## teedubbyaw (Sep 4, 2015)

Chewy20 said:


> Further proving my point that you are not ready to be in the streets...



Que?

Textbooks don't teach anyone much in this field. Learning is done in the field.


----------



## Chewy20 (Sep 4, 2015)

teedubbyaw said:


> Que?
> 
> Textbooks don't teach anyone much in this field. Learning is done in the field.



Hes already saying he wont take care of a pt for fear of being hit...Why should he be in the streets with that mentality?

To each his own, good luck in your endeavors OP.


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## Tigger (Sep 4, 2015)

Even working with people that aren't very smart and give outrageously high first doses of Narcan, I still have yet to encounter a situation that some words and maybe a strong hand on the shoulder could not deal with post-administration. I'm sure there will be a time where I eat these words, but for the most part being hypoxic is kind of tiring I would imagine.


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## NomadicMedic (Sep 4, 2015)

RobertAlfanoNJEMT said:


> Actually the next step is to be in the streets.. There is no more learning.. It's time to gain experience by actually caring for patients



Right, but to do that, you actually have to CARE for patients. Like, take care of them.


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## Chewy20 (Sep 4, 2015)

"There is no more learning."  This is why EMS will always be the joke of the medical world.


----------



## TransportJockey (Sep 4, 2015)

RobertAlfanoNJEMT said:


> Actually the next step is to be in the streets.. There is no more learning.. It's time to gain experience by actually caring for patients


If that's your opinion uou need to be a firefighter and stay out of my profession. There is always something to learn. Especially with the piss poor initial education that BLS providers get. The street is where you get to put into action what you learned in the classroom. Not where you learn everything needed for this job.


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## NomadicMedic (Sep 4, 2015)

...the more i read, the more I smell troll.


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## CALEMT (Sep 4, 2015)

TransportJockey said:


> If that's your opinion uou need to be a firefighter and stay out of my profession. There is always something to learn. Especially with the piss poor initial education that BLS providers get. The street is where you get to put into action what you learned in the classroom. Not where you learn everything needed for this job.



He wouldn't go far in the fire service with that type of mentality believe me.


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## teedubbyaw (Sep 4, 2015)

Chewy20 said:


> "There is no more learning."  This is why EMS will always be the joke of the medical world.



Totes mcgoats didn't even see that part. Lame.


----------



## TransportJockey (Sep 4, 2015)

CALEMT said:


> He wouldn't go far in the fire service with that type of mentality believe me.


He's in Jersey. Seems like Fire and EMS there are all years of tradition unimpeded by progress.


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## CALEMT (Sep 4, 2015)

TransportJockey said:


> He's in Jersey. Seems like Fire and EMS there are all years of tradition unimpeded by progress.



Oh yeah I forgot he's on the east coast...


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## Tigger (Sep 4, 2015)

Remi said:


> My opinion is drifting towards more liberal use of SGA's by BLS in lieu of BVM management.


I do not understand why there is not more emphasis on on BLS placing an airway instead of mask ventilation. With little exception, if the patient can tolerate an OPA, they can tolerate a King or whatnot, and that should be placed. I guess I don't see the downsided of placing an airway in an obtunded patient, aside from those who can have whatever is causing there airway compromise reversed quickly (ie opioids).

Our first responders are actually getting worse with mask ventilation (as am I), as we no longer ventilate cardiac arrest patients until an SGA or ET is in place, if that even happens. For many of our first responders, the only time they use mask ventilate patients is on cardiac arrests, so I expect that they will be even more apprehensive than they already are when it comes to providing ventilation to a patient who is not apneic but still needs to be ventilated.


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## RobertAlfanoNJEMT (Sep 5, 2015)

TransportJockey said:


> He's in Jersey. Seems like Fire and EMS there are all years of tradition unimpeded by progress.


Sorry I forgot that Texas is known as the educational center of the country...


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## chaz90 (Sep 5, 2015)

Let's tone down the personal attacks here and maintain civility. Good discussion so far in this thread, so let's keep it that way.


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## RobertAlfanoNJEMT (Sep 5, 2015)

Tigger said:


> I do not understand why there is not more emphasis on on BLS placing an airway instead of mask ventilation. With little exception, if the patient can tolerate an OPA, they can tolerate a King or whatnot, and that should be placed. I guess I don't see the downsided of placing an airway in an obtunded patient, aside from those who can have whatever is causing there airway compromise reversed quickly (ie opioids).
> 
> Our first responders are actually getting worse with mask ventilation (as am I), as we no longer ventilate cardiac arrest patients until an SGA or ET is in place, if that even happens. For many of our first responders, the only time they use mask ventilate patients is on cardiac arrests, so I expect that they will be even more apprehensive than they already are when it comes to providing ventilation to a patient who is not apneic but still needs to be ventilated.


There is good emphasis on securing an air way... Someone who's airway cannot be maintain by themselves is to be secured with an OPA or NPA... And BVM ventilation is done whenever adequate tidal volume is not achieved... Neither of them are difficult skills


----------



## TransportJockey (Sep 5, 2015)

RobertAlfanoNJEMT said:


> Sorry I forgot that Texas is known as the educational center of the country...


I never said we were. But TX doesn't jave governing agencies for EMS that have actively pushed to LOWER the requirements for BLS. NJ does.


----------



## chaz90 (Sep 5, 2015)

RobertAlfanoNJEMT said:


> There is good emphasis on securing an air way... Someone who's airway cannot be maintain by themselves is to be secured with an OPA or NPA... And BVM ventilation is done whenever adequate tidal volume is not achieved... Neither of them are difficult skills


Let's clear up a couple things here. How do you define a patient's inability to maintain their own airway? 

Neither oropharyngeal or nasopharyngeal adjuncts "secure" a patient's airway. As adjuncts, they assist in very specific parts of the continuum of airway management and have important roles in effectively ventilating a patient. 

Lastly, BVM ventilation is a vitally important skill EMS providers as a whole (BLS and ALS) do a shockingly poor job at performing. I would wager you don't do nearly as good of a job at it as you think you do and have likely had relatively few opportunities to practice it on patients where you measure its effectiveness. Don't overestimate your own abilities as you transition to being a very new EMT freshly out of school.


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## RobertAlfanoNJEMT (Sep 5, 2015)

TransportJockey said:


> I never said we were. But TX doesn't jave governing agencies for EMS that have actively pushed to LOWER the requirements for BLS. NJ does.


It is not easy to become an EMT in NJ... We have some of the toughest standards in the nation... A required 210 classroom hours 6 critical exams through out that, a crap ton of critical practical exams and a standardized state exam


----------



## Flying (Sep 5, 2015)

RobertAlfanoNJEMT said:


> It is not easy to become an EMT in NJ... We have some of the toughest standards in the nation... A required 210 classroom hours 6 critical exams through out that, a crap ton of critical practical exams and a standardized state exam


Null point. Becoming an EMT isn't hard period. CNAs go through more classroom hours and the exams are hardly anything to bother with if you have basic reasoning skills.

What TransportJockey is talking about is how NJ has ended up vetoing multiple initiatives to improve and standardize statewide EMS.


----------



## TransportJockey (Sep 5, 2015)

RobertAlfanoNJEMT said:


> It is not easy to become an EMT in NJ... We have some of the toughest standards in the nation... A required 210 classroom hours 6 critical exams through out that, a crap ton of critical practical exams and a standardized state exam


Im curious where you got the 210 hours figure. NHTSA mandates 120 hours. Although most states go over that on a regular basis (I did initial training in NM and our course was nearly 180 hours seven years ago, before we became a registry state. Which goes with the expanded EMT scope in nm)
The rest of what you describe sounds typical of an emt class


----------



## DesertMedic66 (Sep 6, 2015)

RobertAlfanoNJEMT said:


> It is not easy to become an EMT in NJ... We have some of the toughest standards in the nation... A required 210 classroom hours 6 critical exams through out that, a crap ton of critical practical exams and a standardized state exam


My program in CA was about 208 hours total with 3 critical tests and critical daily exams not including NREMT and the hands on tests. 

You can ask pretty much any EMT or medic in CA and they will tell you it's not that hard to become an EMT...


----------



## RobertAlfanoNJEMT (Sep 6, 2015)

I'm not saying it is hard to become an EMT trust me all I am saying is that NJ isn't the easiest state to become one in..


----------



## EMT2015 (Sep 6, 2015)

RobertAlfanoNJEMT said:


> I'm not saying it is hard to become an EMT trust me all I am saying is that NJ isn't the easiest state to become one in..


Compared to??


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## Chewy20 (Sep 6, 2015)

210 hours?!


RobertAlfanoNJEMT said:


> I'm not saying it is hard to become an EMT trust me all I am saying is that NJ isn't the easiest state to become one in..



So by the statement you are an EMT in more than one state? Thought so.


----------



## CALEMT (Sep 6, 2015)

DesertMedic66 said:


> You can ask pretty much any EMT or medic in CA and they will tell you it's not that hard to become an EMT...



Not just CA, pretty much anywhere. All you need is a semi functioning brain and a pulse to become a EMT...


----------



## NomadicMedic (Sep 6, 2015)

Or as one of my former instructors said, "as long as the check clears..."


----------



## exodus (Sep 6, 2015)

Bullets said:


> NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.
> 
> There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success



What exactly will you be doing with this glucometer and how will it affect your treatment? How will it benefit or prevent harm in your patients?


----------



## RobertAlfanoNJEMT (Sep 6, 2015)

exodus said:


> What exactly will you be doing with this glucometer and how will it affect your treatment? How will it benefit or prevent harm in your patients?


Well if we could use glucometers we wouldn't be giving glucose to hyperglycemic patients, which we are currently encouraged to do


----------



## Flying (Sep 6, 2015)

RobertAlfanoNJEMT said:


> Well if we could use glucometers we wouldn't be giving glucose to hyperglycemic patients, which we are currently encouraged to do


You roll onto the scene and find the patient. How does a person who is currently hyperglycemic present?


----------



## exodus (Sep 6, 2015)

RobertAlfanoNJEMT said:


> Well if we could use glucometers we wouldn't be giving glucose to hyperglycemic patients, which we are currently encouraged to do



When's the last time you have seen an ALOC hypERglycemic patient?  If you have a patient with a diabetic history and they are altered. 99.999% of the time they will be hypOglycemic.

Please show me where it's encouraged to give a hypERglycemic patient oral glucose and encouraged. (How do you even know they're hypERglycemic, you don't have  a glucometer?)

Sure it's an extra tool in the bag and makes it look like you're doing something more, but the costs of outfitting all the units, maintenance, training, protocol writing, insurance additions, etc, etc are very expensive for very little upgrade in care, probably several hundreds of thousands of dollars.  You can use other signs to determine of the patient is possibly hypERglycemic.  This is the same thing as pulse ox on BLS rigs, sure it's nice to have, but there are other ways to see if your patient is perfusing adequately.


----------



## CALEMT (Sep 6, 2015)

RobertAlfanoNJEMT said:


> Well if we could use glucometers we wouldn't be giving glucose to *hypo*glycemic patients, which we are currently encouraged to do



Fixed it for you..

I would like to think that since you claim NJ is the "hardest" state to become a EMT in that you would be able to differentiate HPYERglycemia and HYPOglycemia and between those two who needs glucose and who doesn't.


----------



## teedubbyaw (Sep 6, 2015)

Baby jesus


----------



## RobertAlfanoNJEMT (Sep 6, 2015)

CALEMT said:


> Fixed it for you..
> 
> I would like to think that since you claim NJ is the "hardest" state to become a EMT in that you would be able to differentiate HPYERglycemia and HYPOglycemia and between those two who needs glucose and who doesn't.


No I meant what I wrote... Hyperglocimia is blood sugar that's too high... We are told to give oral glucose to all patients in a diabetic emergency hyper or hypoglycemic!


----------



## Flying (Sep 6, 2015)

RobertAlfanoNJEMT said:


> No I meant what I wrote... Hyperglocimia is blood sugar that's too high... We are told to give oral glucose to all patients in a diabetic emergency hyper or hypoglycemic!


That is the wrong way to go about it. We can certainly say that you were taught incorrectly.

In a true diabetic emergency, grossly hyperglycemic and hypoglycemic patients present very differently and one should be able to tell between them through the basic exam and treat differently based on this. If you don't know the very basics such as these, then you have no business to be talking about having glucometers.


----------



## RobertAlfanoNJEMT (Sep 6, 2015)

Flying said:


> That is the wrong way to go about it. We can certainly say that you were taught incorrectly.
> 
> In a true diabetic emergency, grossly hyperglycemic and hypoglycemic patients present very differently and one should be able to tell between them. If you don't know the very basics such as these, then you have no business to be talking about having glucometers.


The exact words from one of my instructors who had over 30 years of experience riding in a large city was "you can't hurt by giving oral glucose so give it"


----------



## Flying (Sep 6, 2015)

RobertAlfanoNJEMT said:


> The exact words from one of my instructors who had over 30 years of experience riding in a large city was "you can't hurt by giving oral glucose so give it"


I'm willing to bet that same instructor also mentioned that you can't hurt anyone giving oxygen.


----------



## NomadicMedic (Sep 6, 2015)

Well, the basic curriculum does say to administer glucose to a patient "having a diabetic emergency". An altered patient, with a history of diabetes would most likely be hypoglycemic. 

I guess they figure a tube of glucose will help a hypoglycemic and won't really hurt a hyperglycemia patient any worse. Like most of the EMT education, when the only tool you have is a hammer, everything looks like a nail.
(See also: spinal immobilization)


----------



## teedubbyaw (Sep 6, 2015)

Flying said:


> In a true diabetic emergency, grossly hyperglycemic and hypoglycemic patients present very differently



Not completely true. 

And I'm now convinced we're being trolled.


----------



## RobertAlfanoNJEMT (Sep 6, 2015)

Flying said:


> I'm willing to bet that same instructor also mentioned that you can't hurt anyone giving oxygen.


Yup


----------



## RobertAlfanoNJEMT (Sep 6, 2015)

teedubbyaw said:


> Not completely true.
> 
> And I'm now convinced we're being trolled.


I agree with you.. All patients present and react very differently.. As for the troll part stop acting like a middle school adolescent who was just given a keyboard and wifi connection


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## teedubbyaw (Sep 6, 2015)

I've been acting this way on the internet since 3rd grade.


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## RobertAlfanoNJEMT (Sep 6, 2015)

teedubbyaw said:


> I've been acting this way on the internet since 3rd grade.


I believe it!


----------



## CALEMT (Sep 6, 2015)

RobertAlfanoNJEMT said:


> No I meant what I wrote... Hyperglocimia is blood sugar that's too high... We are told to give oral glucose to all patients in a diabetic emergency hyper or hypoglycemic!



Umm you are aware that one of the contraindications for oral glucose is a BLG >60 right? Even without a glucometer you should be able to tell which pt has a high BGL and which has a low BGL.

A person with a high BGL certainly doesn't need even more glucose within the body. Theres a reason that medications have contraindications and one of them for oral glucose happens to be a BLG >60. Even without a glucometer you can tell who needs glucose and who doesn't.

If you remember from EMT school the body needs two things to maintain blood sugar homeostasis: insulin and glucagon. Insulin levels (in the body) naturally rise when blood glucose levels rise (ex. eating a meal). Cells within the body respond to this by taking glucose from the blood, and as a result you lower the blood glucose level. Now on the other side of things glucagon is secreted when the body's blood glucose levels are to low (ex. you skipped a meal). Glucagon's job is to help the liver release stored glucose and whaha blood glucose levels rise. Same concept applies to the prehospital world, when sugar is low you give more sugar. When sugar is high you don't give more sugar.


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## RobertAlfanoNJEMT (Sep 6, 2015)

CALEMT said:


> Umm you are aware that one of the contraindications for oral glucose is a BLG >60 right? Even without a glucometer you should be able to tell which pt has a high BGL and which has a low BGL.
> 
> A person with a high BGL certainly doesn't need even more glucose within the body. Theres a reason that medications have contraindications and one of them for oral glucose happens to be a BLG >60. Even without a glucometer you can tell who needs glucose and who doesn't.
> 
> If you remember from EMT school the body needs two things to maintain blood sugar homeostasis: insulin and glucagon. Insulin levels (in the body) naturally rise when blood glucose levels rise (ex. eating a meal). Cells within the body respond to this by taking glucose from the blood, and as a result you lower the blood glucose level. Now on the other side of things glucagon is secreted when the body's blood glucose levels are to low (ex. you skipped a meal). Glucagon's job is to help the liver release stored glucose and whaha blood glucose levels rise. Same concept applies to the prehospital world, when sugar is low you give more sugar. When sugar is high you don't give more sugar.


Yes I know all of that.. I just finished a year of anatomy and physiology but thanks for the lesson! With out testing the glucose level you cannot be CERTAIN if it is hypo or hyperglycemia... All patients are different and react differently to what is going on in their body..


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## RobertAlfanoNJEMT (Sep 6, 2015)

My father is a diabetic and has gone to the hospital via ambulance 2 or 3 times for hyperglociamia.. It's not always hypoglycemia don't put those blinders on guys!


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## EMT2015 (Sep 6, 2015)

RobertAlfanoNJEMT said:


> As for the troll part stop acting like a middle school adolescent who was just given a keyboard and wifi connection


Buddy, you really need a attitude adjustment.  I have been watching this thread for a little while now and have not said anything. But, I have gotten tired of seeing you disrespect everyone on here who are only trying to help you learn.  I completely agree with a lot of people on here that you have been taught incorrectly and to be honest it feels like you think that you know it all.  Take a note from someone who's still new to the EMS field, what you learn in class and what you learn in the field can be completely different sometimes.  My advice is that you start listening to everyone here who has tried to help you learn the correct information.  As your peer, I will be completely honest and say that I fully believe that you are not ready for the streets and need to do some more research.


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## RobertAlfanoNJEMT (Sep 6, 2015)

EMT2015 said:


> Buddy, you really need a attitude adjustment.  I have been watching this thread for a little while now and have not said anything. But, I have gotten tired of seeing you disrespect everyone on here who are only trying to help you learn.  I completely agree with a lot of people on here that you have been taught incorrectly and to be honest it feels like you think that you know it all.  Take a note from someone who's still new to the EMS field, what you learn in class and what you learn in the field can be completely different sometimes.  My advice is that you start listening to everyone here who has tried to help you learn the correct information.  As your peer, I will be completely honest and say that I fully believe that you are not ready for the streets and need to do some more research.


Seriously dude? I've been the one being attacked this whole time... I was called a troll, they were saying that since I'm in NJ I don't know what I am talking about etc etc.. I aprieciate people who try to help me but not people who are going to be rude in the process.. I will not stand for being attacked and called unintelligent when most of the people saying it have not a whole lot more education than me. I may be new to the EMS life but I am not new to medicine.. I have been researching medicine, the way the body reacts, and anatomy and physiology for most of my life. As well as volunteering in a local ER... I know my **** and am willing and thirsty to learn more if people are willing to be respectful and not talk down to me!


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## Carlos Danger (Sep 6, 2015)

RobertAlfanoNJEMT said:


> Seriously dude? I've been the one being attacked this whole time... I was called a troll, they were saying that since I'm in NJ I don't know what I am talking about etc etc.. I aprieciate people who try to help me but not people who are going to be rude in the process.. I will not stand for being attacked and called unintelligent when most of the people saying it have not a whole lot more education than me. *I may be new to the EMS life but I am not new to medicine.. I have been researching medicine, the way the body reacts, and anatomy and physiology for most of my life. As well as volunteering in a local ER... I know my **** and am willing and thirsty to learn more if people are willing to be respectful and not talk down to me!*



Either the worst trolling or the awesomest Ricky Rescuing I've seen in a while. Either way, rather entertaining.


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## teedubbyaw (Sep 6, 2015)

CALEMT said:


> Even without a glucometer you can tell who needs glucose and who doesn't.



Robert does have a valid point. An old frame of mind/practice was giving glucose to altered pt's with a possible history of diabetes. Both hypo and hyperglycemia can present similarly, and a BLS provider without full understanding of the pathophysiology behind both processes, may not be able to differentiate the two between signs/symptoms.


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## EMT2015 (Sep 6, 2015)

RobertAlfanoNJEMT said:


> may be new to the EMS life but I am not new to medicine.. I have been researching medicine, the way the body reacts, and anatomy and physiology for most of my life


One question: Your profile says that you're 18, so how can you have been doing this for most of your life?


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## RobertAlfanoNJEMT (Sep 6, 2015)

EMT2015 said:


> One question: Your profile says that you're 18, so how can you have been doing this for most of your life?


I was a curious child... I didn't get out of the house much or have many friends! Haha


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## RobertAlfanoNJEMT (Sep 6, 2015)

teedubbyaw said:


> Robert does have a valid point. An old frame of mind/practice was giving glucose to altered pt's with a possible history of diabetes. Both hypo and hyperglycemia can present similarly, and a BLS provider without full understanding of the pathophysiology behind both processes, may not be able to differentiate the two between signs/symptoms.


Thank you!


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## EMT2015 (Sep 6, 2015)

RobertAlfanoNJEMT said:


> I was a curious child... I didn't get out of the house much or have many friends! Haha


Sounds like a homeschooler?


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## RobertAlfanoNJEMT (Sep 6, 2015)

EMT2015 said:


> Sounds like a homeschooler?


Nope public all the way! Haha


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## Jim37F (Sep 6, 2015)

I'll agree in my EMT school they taught us the same "known diabetic acting strangely? Give sugar, it'll save a hypOglycemic patient without harming a hypERglycemic patient" mantra. However we were also taught cool and clamy give candy, hot and dry, their sugar is too high. 

Also when you're fresh out a school, you're the new guy, the FNG, the probie, so when talking to a bunch of experienced providers who are all saying the same thing and your arguing and touring your basic training as being all high and mighty? Dude its like a private arguing with a bunch of seasoned sergeants who've been in combat....basically no bueno, you are wrong. Period. Hell I've been in EMS two years and I'm STILL the FNG who's learning the difference between the real world and the text book. Have a little humility and you'll go far.


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## RobertAlfanoNJEMT (Sep 6, 2015)

Jim37F said:


> I'll agree in my EMT school they taught us the same "known diabetic acting strangely? Give sugar, it'll save a hypOglycemic patient without harming a hypERglycemic patient" mantra. However we were also taught cool and clamy give candy, hot and dry, their sugar is too high.
> 
> Also when you're fresh out a school, you're the new guy, the FNG, the probie, so when talking to a bunch of experienced providers who are all saying the same thing and your arguing and touring your basic training as being all high and mighty? Dude its like a private arguing with a bunch of seasoned sergeants who've been in combat....basically no bueno, you are wrong. Period. Hell I've been in EMS two years and I'm STILL the FNG who's learning the difference between the real world and the text book. Have a little humility and you'll go far.


Still doesn't mean I should tolerate their rudeness...


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## luke_31 (Sep 6, 2015)

RobertAlfanoNJEMT said:


> Still doesn't mean I should tolerate their rudeness...


From what I've seen they have been very direct with you, if you're not familiar with how EMS is you could see it as being rude but they are trying to educate you on how to best treat your patients in the field. It's very rare for a patient to truly present how the book describes them. I've have quite a few serious patients who just thought they had the touch of the flu and weren't feeling well. Bottom line a good through assessment always needs to be done to avoid missing something serious.  Also medicine changes over time as new studies are conducted which have shown how lots of our treatments don't work, can be dangerous, or are based on tradition rather than any evidence of benefit for the patient. Oxygen, spinal immobilization, and drugs for cardiac arrest are some of the ones I can think of off the top of my head.


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## RobertAlfanoNJEMT (Sep 7, 2015)

luke_31 said:


> From what I've seen they have been very direct with you, if you're not familiar with how EMS is you could see it as being rude but they are trying to educate you on how to best treat your patients in the field. It's very rare for a patient to truly present how the book describes them. I've have quite a few serious patients who just thought they had the touch of the flu and weren't feeling well. Bottom line a good through assessment always needs to be done to avoid missing something serious.  Also medicine changes over time as new studies are conducted which have shown how lots of our treatments don't work, can be dangerous, or are based on tradition rather than any evidence of benefit for the patient. Oxygen, spinal immobilization, and drugs for cardiac arrest are some of the ones I can think of off the top of my head.


I agree and I'm all about learning and continuing education but I don't like when people try to shame me into believing I need a lesson from them.. Where I come from to get respect you have to give it too.. Maybe that's just a Jersey thing!


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## Flying (Sep 7, 2015)

You signed your own warrant by saying "there is no more learning" in your first few posts on this forum. I like the enthusiasm, but even that needs to take a back seat at some point.

On the topic of respect, I was taught to defer to my elders. In the case of these forums, my elders in knowledge and well-informed experience.


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## RedAirplane (Sep 7, 2015)

I was also taught that altered plus possible DM history gets glucose.


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## RobertAlfanoNJEMT (Sep 7, 2015)

Flying said:


> You signed your own warrant by saying "there is no more learning" in your first few posts on this forum. I like the enthusiasm, but even that needs to take a back seat at some point.
> 
> On the topic of respect, I was taught to defer to my elders. In the case of these forums, my elders in knowledge and well-informed experience.


I misspoke on that one I was trying to say that I will no longer be in a classroom learning I will now be learning on the streets.. But of corse everyone on here only read "there's no more learning"


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## Bullets (Sep 7, 2015)

exodus said:


> What exactly will you be doing with this glucometer and how will it affect your treatment? How will it benefit or prevent harm in your patients?


Rule out a stroke, or rule it in and activate the Code Neuro


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## Tigger (Sep 7, 2015)

RobertAlfanoNJEMT said:


> There is good emphasis on securing an air way... Someone who's airway cannot be maintain by themselves is to be secured with an OPA or NPA... And BVM ventilation is done whenever adequate tidal volume is not achieved... Neither of them are difficult skills


Yea, I don't think you have any idea what you are doing. Basic adjuncts don't secure an airway and mask ventilation is far from easy. 

But you aren't doing any more learning, so I guess it's moot.


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## DesertMedic66 (Sep 7, 2015)

Tigger said:


> Yea, I don't think you have any idea what you are doing. Basic adjuncts don't secure an airway and mask ventilation is far from easy.
> 
> But you aren't doing any more learning, so I guess it's moot.


Thank you for typing that out so I didn't have to haha


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## exodus (Sep 7, 2015)

Bullets said:


> Rule out a stroke, or rule it in and activate the Code Neuro



Give the glucose, if they don't improve within 3 minutes, it's probably neuro.  And why will a BLS unit be running an ALOC call without an ALC unit enroute or there? That's not going to happen except for very rare scenarios.  It's also a rarity for hyPOglycemia to perfectly mimic a stroke, it happens, but is pretty rare.

What would the problem be with simply activating the team anyway?


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## RedAirplane (Sep 7, 2015)

Back to the Narcan issue...

It's not in my scope of practice but it's coming in some areas. I'm sure there's training on it when you go to an area that has it. 

But my somewhat stupid question is... If they're not breathing, how do you know if the had an opiate overdose? Can't exactly ask.  Or do you give it out to any respiratory arrest?

(Unless the bottle of morphine is lying on the patients side... Might it be an EtOH overdose? Medical cause?)


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## teedubbyaw (Sep 7, 2015)

RedAirplane said:


> Back to the Narcan issue...
> 
> It's not in my scope of practice but it's coming in some areas. I'm sure there's training on it when you go to an area that has it.
> 
> ...



Pinpoint pupils is a good place to start.


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## DesertMedic66 (Sep 7, 2015)

RedAirplane said:


> Back to the Narcan issue...
> 
> It's not in my scope of practice but it's coming in some areas. I'm sure there's training on it when you go to an area that has it.
> 
> ...


Pupils are a good indicator. Also drug paraphernalia on or around the scene (needles, spoons, aluminum foil, cotton balls, lighters, pipes, etc). Track marks on the patient. You, other responders, or bystanders on scene may be familiar with the patient also (before anyone tries to twist my words) I'm not saying that just because a patient has a history of using illegal drugs means that is the medical issue with them currently.


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## CALEMT (Sep 7, 2015)

RedAirplane said:


> Back to the Narcan issue...
> 
> It's not in my scope of practice but it's coming in some areas. I'm sure there's training on it when you go to an area that has it.
> 
> ...



Edit: Pretty much what Desert said... beat me to it. Situational awareness.


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## Melbourne MICA (Sep 10, 2015)

I must admit I'm really surprised by many comments. Narcan has been standard here for years for all opiate overdoses. Its safe and effectiveif the delivery method is well thought through. Years back our protocol was IV Narcan by MICA medics only with road crews ventilating. Not a good combo because IV is too abrupt wakes the pt quick, so MICA's would tell the crews to hold off on ventilation for a bit till they got a line in and administered. Result was heroin user waking up in withdrawal and hypoxic hangover big time. Guess who he took aim at for feeling this way? Later it was changed. Lots of good ventilation and IM Narcan. Slow gentle onset, no hypoxia. Result? "Urgh sorry guys, was I really out of it -od'd?" It has been one of our most effective CPG redesigns ever. The other thing to think about is prescription med abuse/theft/doc shopping (mostly OTC opiates like OxyContin) is now larger than all the illicit drugs combined. So you may well need Narcan for all those codeine and Oxy OD's. Give it IM with lots of the good gas before hand.

MM


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