# Narcan, or Not.



## Phillyrube (Sep 20, 2018)

Ok, watching Nightwatch on AETV.  First call, overdose.  Cool.  Get him in the box, O2, pulseox. EtCO2.,   Fire department bagging guy.  Start an IV, and "Narcan is in".  Next second guy is up, with like 8 people trying to hold him down.  Blood from the pulled out IV sprays everyone.   Finally guy calms down after being restrained every which way.

Sound familiar?  How do you handle it?   Our protocols call for 2-4 mg narcan IV or IN.  With the advent of CO2 monitoring, do we need to throw the entire dose on the patient?  We've been giving the patient 1-2 mg narcan, and monitor.  If the numbers are good, let them sleep.  Now, we gotta train the cops not to be so quick with their INs.  Had a couple get pissed cause the woke up the pateint, who is now combative, and I made them ride in with us (helps that I was also a PD supervisor).

What say you?

Carry on, boys.


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## StCEMT (Sep 20, 2018)

Here lately? Narcan drip. NPA/EtCO2/NRB or BVM if ventilations are too low. **** around for a few minutes while EtCO2 and O2 sat returns to a happy place then start an IV. 2mg Narcan in 250cc. Titrate to effect just like D10.

No fights. No puke. Just slow, gentle wake ups.


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## NPO (Sep 20, 2018)

2-4mg IV is probably way more than you need. I give 0.5mg IV or 2mg IN to start. I've never had a patient wake up angry, vomiting or combative. 

Also, giving it slowly is a big deal too.


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## NomadicMedic (Sep 21, 2018)

Titrate to effect. A little bit of Narcan, a BVM, and some patience go a long way.


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## DrParasite (Sep 22, 2018)

I live for the day where I get to give 2 mg of narcan and the dead will rise..... It's on my bucket list....

I've seen the combative narcan response once, and the situation was exactly as you drivingde.. . Most of the time they aren't that bad.

I do think slowly waking a person up with narcan while assisting respirations with a bvm is better than giving the the whole dose hard and fast, there's something to be said about thrm walking down the steps or out the door under their own powera control and breathing in their own.


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## cprted (Sep 22, 2018)

I'm fully onboard with @NomadicMedic and @DrParasite.  There is absolutely no reason to slam 2mg IV into anyone as a first line treatment. Once you've established good ventilations, the emergency is over.  Take your time and wake them up slowly.

Establish good ventilations with BVM.  Just bag them for a minute or two to correct hypoxemia and hypercapneia.  Then I usually start with 0.4-0.8mg of Naloxone IM. 80% I don't have to give a second dose.  Very rare to have anyone come up combative. Usually they start to open their eyes, we pull the bvm away and tell them to take their OPA out. That's how the overwhelming majority of my OD calls go.


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## CCCSD (Sep 22, 2018)

Dr P, for your amusement:

On an OD call years ago.

Baby momma: “ He’s dead! He’s dead!”

(Me pushing Narcan, doing PM stuff) Pt wakes up, starts getting grabby. Crowd gasps, “oooohhhhh...”

Baby momma: “He’s alive! Oh Lord! Thank you Baby Jesus,”

Me: “Don’t thank The Lord, Lady. Thank me and DuPont Chemicals.”

Baby momma: “Wha’?”

I do miss it at times...


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## NPO (Sep 22, 2018)

CCCSD said:


> Dr P, for your amusement:
> 
> On an OD call years ago.
> 
> ...


Reminds me of that scene from Mother Jugs & Speed


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## Bullets (Sep 22, 2018)

2mg IN and wait until they wake up. I am loathe to start a line on opiod ODs since i have IN drugs and a BVM


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## CCCSD (Sep 22, 2018)

NPO, 

that is the hands down BEST EMS movie ever made!
UNITY+F&B!


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## Jim37F (Sep 23, 2018)

NPO said:


> Reminds me of that scene from Mother Jugs & Speed


I was just about to say something about Ibebangin...


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## jwk (Sep 23, 2018)

I am light years out of EMS and treating OD.  But the amount of Narcan used, by my practice, is huge!  As a couple have noted, if you're ventilating and oxygenating your patient (I assume SaO2 being used), your apneic emergency has passed.  You can always give more Narcan if needed.  Remember that CO2 has anesthetic properties at higher ranges, which in an apneic patient is quite possible.  It takes a little time to get the EtCO2 down.

https://www.openanesthesia.org/carbon_dioxide/


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## DrParasite (Sep 23, 2018)

NPO said:


> Reminds me of that scene from Mother Jugs & Speed


reminds me of a scene from Bringing out the Dead


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## CCCSD (Sep 23, 2018)

Thank God I did this before all those movies... (except MJ+S).


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## johnrsemt (Sep 26, 2018)

Bad thing is with PD having Narcan;  most people that are down and not breathing due to OD's are going to be brain dead by the time PD gets there so it won't help a lot.

PT job we give Narcan a lot.  ALOT.   I try to keep it at 0.2mg per dose, and titrate it;  I would rather have to bag a patient during parts of a  120 mile transport than fight them.

Plus Narcan isn't doing by itself.  Too many cocktail OD's out there.


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## NPO (Sep 26, 2018)

johnrsemt said:


> Bad thing is with PD having Narcan;  most people that are down and not breathing due to OD's are going to be brain dead by the time PD gets there so it won't help a lot.



That's not actuate. 

PD is giving narcan to the "fresh" ODs. The ones with brain damage are usually in cardiac arrest.


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## RocketMedic (Sep 27, 2018)

+1 on the polypharm ODs


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## KingCountyMedic (Sep 27, 2018)

We will go 0.2 - 0.4 mg to start, IN, IM, IV. Our LEO's carry 4mg nasal spray that gives the entire 4mg in one shot. They are also trained to provide rescue breathing prior to giving the Narcan. Our BLS Fire folks carry 2mg Nasal and are trained to give 1mg and BVM, wait for them to wake up and wait for us. We are dispatched to all overdoses that get IN Narcan from LEO or Fire. We will evaluate, give more if needed, maybe some Zofran if needed etc.


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## johnrsemt (Sep 28, 2018)

That is good that some Police Departments are training in rescue breathing and when to do it;  and it is good for fresh OD's.  
Where I work PT (where we have a major OD problem) we and the PD and fire have about a 100 X 90 mile coverage area.  There is 4 fire departments (2 west of our town, and 2 in our town {our town straddles state line and is actually 2 towns, with basically same name}).  But we get OD's 40 or 50 miles out on the highways, that may or may not have a crash involved, so the PD gets there faster (120 mph against 80 for us).  They give Narcan, and rescue breathing (BVM) but usually doesn't do much.
A lot of times with family members who have Narcan you get the same results unless the family member sees the druggie go down it may be a while before they find the OD, and give Narcan; and they usually don't do rescue breathing.  And they think that if they give Narcan that is all that has to happen:  No CPR or anything.
Narcan the miracle drug  except when it isn't


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## KingCountyMedic (Oct 1, 2018)

Our LEO folks are really big on EMS calls, they all have Defib units, trauma kits, Narcan. I've had cops beat us to dozens of CPR calls over the years and they have started CPR, shocked, and achieved ROSC prior to our arrival. Just south of us in Pierce County the Tacoma Fire Department is handing out Narcan on calls to family members when they show up on OD's. I believe they got a grant to do it.


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## StCEMT (Oct 1, 2018)

KingCountyMedic said:


> Our LEO folks are really big on EMS calls, they all have Defib units, trauma kits, Narcan. I've had cops beat us to dozens of CPR calls over the years and they have started CPR, shocked, and achieved ROSC prior to our arrival. Just south of us in Pierce County the Tacoma Fire Department is handing out Narcan on calls to family members when they show up on OD's. I believe they got a grant to do it.


That's awesome for them. Had one arrest I think PD make an impact on by beating us there. I've had them put a TQ or two on for me as well.


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## Never2Old (Oct 2, 2018)

*EMS Crew:* BVM, IV, titrate Narcan IV to effect, restore respiration, transport. 
*PD:* 4mg Nasal Narcan, rinse and repeat till all the responding PD has used their Narcan and the spare in the trunk, or the patient drowns. 

I am an advocate of removing Narcan from PD, and instead giving them a BVM and an AED. Couldn't tell you how many many times the PD is pushing Narcan when they should be pushing the chest.


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## KingCountyMedic (Oct 2, 2018)

Never2Old said:


> *EMS Crew:* BVM, IV, titrate Narcan IV to effect, restore respiration, transport.
> *PD:* 4mg Nasal Narcan, rinse and repeat till all the responding PD has used their Narcan and the spare in the trunk, or the patient drowns.
> 
> I am an advocate of removing Narcan from PD, and instead giving them a BVM and an AED. Couldn't tell you how many many times the PD is pushing Narcan when they should be pushing the chest.



It's all about training and having an involved Medical Director. Our cops save lives on a daily basis in King County, Washington. The Police Commander that oversees their EMS Training is a 20+ year EMT and a Senior EMT Instructor. Our Paramedics assist in "training the trainers" and they take pride in the work they do. Our LEO aren't allowed to administer their Narcan until they've checked for a pulse, start CPR if needed and apply their AED and given rescue breaths (at least 2)

Most LEO agencies are carrying Narcan because they are afraid of officers being exposed to Fentanyl and they want to be able to help their fellow officers, not a bad thing....


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## DrParasite (Oct 2, 2018)

KingCountyMedic said:


> Most LEO agencies are carrying Narcan because they are afraid of officers being exposed to Fentanyl and they want to be able to help their fellow officers, not a bad thing....


That's actually a really bad reason; how often are they actually exposed to Fentanyl?  Better question: how many times in the past 12 months have they administered narcan to a fellow officer due to an exposure?

Now compare that to have given it to a member of the public.....

Don't get me wrong, I 100% agree that officers should and will do whatever they can to help their fellow brother in blue... but the amount of officers who die from a fent exposure, or even suffer negative irreversible effects before EMS can arrive, is tiny, at least compared to other things that kill and injures officers.

It's waaaay easier to give narcan than use a BVM.  PD are not the only ones who are guilty of this.  And as a FF, I look forward to the day when I can push Narcan and wake the dead.  But if they aren't breathing, the solution isn't more narcan, it's manual ventilations, preferably with a BVM.  too many first responders forget to do this part... 

remember we are titrating till they are breathing, not until they are awake (but I still want to wake the dead with narcan).


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## KingCountyMedic (Oct 2, 2018)

DrParasite said:


> That's actually a really bad reason; how often are they actually exposed to Fentanyl?  Better question: how many times in the past 12 months have they administered narcan to a fellow officer due to an exposure?
> 
> Now compare that to have given it to a member of the public.....
> 
> ...



Here in Washington State in the past 12 months there's probably been fewer than 6 LEO's getting Narcan either from a fellow officer or self admin and probably in most cases didn't actually need to deploy it to begin with. There have been dozens and dozens of instances where first arriving LEO has successfully performed rescue breathing and given Narcan to appropriate patients and had good outcomes. The program is working well for us but we maintain a high level of control and training. For a cop, Narcan in your kit is one more tool you can use to save a life. Every cop in King County has a kit that contains Narcan, 2 CAT tourniquets, quick clot, HyFin Chest seal, trauma dressings, rescue mask, and AED. The are required to do quarterly training on everything same as our EMT's and many of the officers are required to be an EMT depending on where they work and their assignment.


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## DrParasite (Oct 3, 2018)

KingCountyMedic said:


> Here in Washington State in the past 12 months there's probably been fewer than 6 LEO's getting Narcan either from a fellow officer or self admin and *probably in most cases didn't actually need to deploy it to begin with*.


I bolded the important part.  That part also validates my statatement in in response to your claim that "Most LEO agencies are carrying Narcan because they are afraid of officers being exposed to Fentanyl and they want to be able to help their fellow officers" is a bad idea, because they aren't using it for it's intended purposes, or when it's actually needed.

As for the rest (giving it to OD victims to get them breathing again, and not waking them up), I'm totally in favor of it.  If narcan is used to restore respirations, than that's a good thing.  especially if they are using a rescue mask to ensure they are breathing, and not just staring at the patient until they wake up (not saying Washington cops do this, but I have seen other LEO officers and firefighters do this)





KingCountyMedic said:


> many of the officers are required to be an EMT depending on where they work and their assignment.


Yeah, i work with a bunch of firefighters who are required to be EMTs as a condition of their job.... I question their levels of competency, their knowledge of A&P, and I wouldn't trust most to treat me unless I was near death.  Unless you have spent time on an ambulance (preferably full time with a lot of patient contacts), I am going to be skeptical when you say "I'm an EMT and I know what I'm doing."


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## Tigger (Oct 3, 2018)

KingCountyMedic said:


> Most LEO agencies are carrying Narcan because they are afraid of officers being exposed to Fentanyl and they want to be able to help their fellow officers, not a bad thing....


I hope that is not true, as I am sure you aware that all the fentanyl "exposure" stories are complete BS.


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## johnrsemt (Oct 3, 2018)

Good I am glad it is working for you;  thrilled the police are that active on EMS calls.

At my PT job the police are usually doing CPR when EMS and Fire arrive;  I don't know if they have AED's or not,  never noticed.  Then again I have never been 1st truck in on an arrest: so everything is usually set up when I get there


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## Rommel (Oct 12, 2018)

Interesting that your PDs have this kind of access and skill. Has merit in high frequency areas I suppose. 

Last time I was beaten by cops to a "cardiac arrest" the officer was doing sensational compressions, only the psych pt was playing dead and doing a great job at it. I still let him believe he saved her life ;o)

Out statewide protocol directs 100mcg IV/IM per dose at 2min or greater intervals until the desired response + airway management to a max of 2mg, so a little more conservative than some protocols. Its better than the old school 2mg straight up followed by the wrestling match.


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## CCCSD (Oct 13, 2018)

Tigger said:


> I hope that is not true, as I am sure you aware that all the fentanyl "exposure" stories are complete BS.



Nope. There ARE multiple verified exposures. I suggest you do a search. The latest is Alameda County SO, Narcotics Task Force. Feel free to contact the DEA, as they are the lead agency in the collection and verification of these reports.


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## Tigger (Oct 14, 2018)

I will wait until toxicologists actually verify any of these stories. Meanwhile, here is the ACMT position paper on the very subject. https://www.acmt.net/_Library/Positions/Fentanyl_PPE_Emergency_Responders_.pdf

A bunch of cops giving each other narcan does not mean that they were exposed.


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## CCCSD (Oct 14, 2018)

A single paper, in direct contrast to documented fact, does not mean they were not exposed.

Your responses show EXACTLY why I teach Narcan to LE. You have already made up your mind that you know more than anyone else, and that all cops are liars.

I’m glad to know that my guys will be ok and have a fighting chance if they are exposed, instead of having some medic withhold treatment. Besides, better to spray than not. 

So when you do kill a cop because you felt Narcan wasn’t needed, make sure you fess up to the family and all my Brothers and Sisters out there.


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## DrParasite (Oct 14, 2018)

CCCSD said:


> A single paper, in direct contrast to documented fact, does not mean they were not exposed.


you're right.  After all, the documented facts should over ride the position of the American College of Medical Toxicology (ACMT) and American Academy of Clinical Toxicology (AACT).  I mean, it's not like TOXICOLOGISTS would know anything about exposures.....


CCCSD said:


> So when you do kill a cop because you felt Narcan wasn’t needed, make sure you fess up to the family and all my Brothers and Sisters out there.


I have heard no reports of narcan being withheld from law enforcement by EMS, resulting .... and several cases of it being administered to conscious officers following an exposure.





CCCSD said:


> Nope. There ARE multiple verified exposures. I suggest you do a search. The latest is Alameda County SO, Narcotics Task Force. Feel free to contact the DEA, as they are the lead agency in the collection and verification of these reports.


I'll call you bluff: you got an contact at the DEA I can direct this request to?  an email or phone number would be great, sent via PM.  

Oh, and I don't doubt that they were exposed; heck, you can walk into a heroin den and be exposed.  the question is, were they exposed to the level where they were knocked unconscious and experienced decreased respirations, necessitating the narcan administration?  or did they give each other narcan just because they felt icky, because they weren't wearing the recommended PPE?

BTW, here is the CDC statement on fentanyl: https://www.cdc.gov/niosh/topics/fentanyl/risk.html and https://www.cdc.gov/niosh/topics/fentanyl/healthcareprevention.html

And I know the CDC aren't cops, but they have some smart people working there *Fentanyl Exposure Risks for Law Enforcement and Emergency Response Workers*

And the DEA recommendation: https://www.dea.gov/press-releases/2016/06/10/dea-warning-police-and-public-fentanyl-exposure-kills


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## StCEMT (Oct 14, 2018)

We aren't going to kill anyone by withholding Narcan. I do it all the time and guess what? They live. Exposure does not mean they are going to be apneic and unresponsive.

Does it hurt to give? I suppose not. However, there is a time to give Narcan, and an exposure is not one of them.

You say this as if anyone of us, Tigger especially, wouldn't ensure that an officer that legitimately was exposed got the best and (emphasis here-->)most appropriate care we could offer, which is ****ing ridiculous.


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## DrParasite (Oct 14, 2018)

CCCSD said:


> The latest is Alameda County SO, Narcotics Task Force.


Saving people from having to search for it:
https://www.eastbaytimes.com/2018/06/26/opioid-antidote-saves-alameda-sheriffs-officers-lives/
https://www.nbcbayarea.com/investig...-Silence-on-Fentanyl-Poisoning-494294131.html
https://www.jems.com/articles/pt/20...ive-potentially-lethal-fentanyl-exposure.html


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## VentMonkey (Oct 14, 2018)

Wait, so exposure now = overdose requiring Narcan administration? What have multiple LE agencies done for decades with the countless amounts of designer opioid epidemics prior to giving every cop Narcan kits? 

I don't think _training_ first responders to administer Narcan to be "life-saving"; _educating_ them, yes. But those two words alone carry the heaviest of connotations pointing towards opposite directions.


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## Phillyrube (Oct 14, 2018)

I had a couple calls where school nurses hit kids with autoinjectors of epi because the kid saw someone with a PBJ sammich and ran screaming to the nurses office.  Don't need prophylactic narcan.


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## KingCountyMedic (Oct 15, 2018)

I think it's great having LEO carry and give Narcan. Our LEO agencies are very well trained in providing medical aid. We are at a time right now, thanks in part to the media, that they have to carry it. It's being giving out to family members of addicts, it's given out at needle exchange programs etc. It's unfortunate but the fact is you carry it or you are asking for lawsuits. There have been many cases of officers using it on themselves or fellow officers when there was no exposure. I don't really have a problem with that at all. There has also been cases where it was needed and it helped. Our LEO in King County are using it on an almost weekly basis and doing a lot of good. I also have many friends that are cops and they face a ton of threats on a daily basis that most EMS folks can't even begin to comprehend. If my buddies feel a little bit safer because they have a nasal shooter of Narcan in their pocket and that helps alleviate a little bit of the stress of going out there and dealing with bad guys then I say GOOD DEAL.


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## StCEMT (Oct 15, 2018)

I don't mind that they have it, I just think it's use needs to be properly taught and comprehended. Just like tourniquets. One of the more severe shootings I ran this summer had a TQ in place by PD and appropriately so. It made a difference, because it was a 3 person shooting spread out over about 1/4mile and we were the second unit in having to figure out a location.  I am all for them having the right tools in stuff like this, because I've seen the benefit. I just want them to know either A. How to progress up treatments before jumping to the new addition or B. Knowing what people you SHOULD skip everything and go to a TQ or Narcan. I don't think it should just be added to their kit with a 5 minute summary, pat on the back, and a go get em.


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## Tigger (Oct 15, 2018)

CCCSD said:


> A single paper, in direct contrast to documented fact, does not mean they were not exposed.
> 
> Your responses show EXACTLY why I teach Narcan to LE. You have already made up your mind that you know more than anyone else, and that all cops are liars.
> 
> ...


Oh my. So much to unpack here.

So the thing with the "single paper" is that it's the summation of available research as put forth by legitimate subject matter experts, of which none of us are. So yes, that is the _one_ I posted. You're right though, the number of papers that exist on a particular subject is how one decides if a point is valid or not.

Not sure where you got the impression that I would withhold treatment to the theoretical officer that's hypoxic and hypercapnic. If the patient is presents as such secondary to likely opioid exposure, I suppose I might give some Narcan. I might also just RSI them given the fact we have no idea what the "white powder" in question is. But yea, kill a cop through gross negligence? Not sure where you got that impression from.


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## Tigger (Oct 15, 2018)

KingCountyMedic said:


> I think it's great having LEO carry and give Narcan. Our LEO agencies are very well trained in providing medical aid. We are at a time right now, thanks in part to the media, that they have to carry it. It's being giving out to family members of addicts, it's given out at needle exchange programs etc. It's unfortunate but the fact is you carry it or you are asking for lawsuits. There have been many cases of officers using it on themselves or fellow officers when there was no exposure. I don't really have a problem with that at all. There has also been cases where it was needed and it helped. Our LEO in King County are using it on an almost weekly basis and doing a lot of good. I also have many friends that are cops and they face a ton of threats on a daily basis that most EMS folks can't even begin to comprehend. If my buddies feel a little bit safer because they have a nasal shooter of Narcan in their pocket and that helps alleviate a little bit of the stress of going out there and dealing with bad guys then I say GOOD DEAL.


Other ways to alleviate said stress might be to just provide education?

I am totally for law enforcement carrying narcan to be clear. I think they can make a huge difference just given their likely response time to overdoses.


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## KingCountyMedic (Oct 15, 2018)

Tigger said:


> Other ways to alleviate said stress might be to just provide education?
> 
> I am totally for law enforcement carrying narcan to be clear. I think they can make a huge difference just given their likely response time to overdoses.



We provide both, not all LEO's are fortunate enough to have a EMS Medical Director and EMS Agency that takes an active role in their training and education. Those folks probably feel a lot better having it "just in case" 

I'd love to see more education for not only LEO but for all EMS providers....


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## Carlos Danger (Oct 15, 2018)

CCCSD said:


> A single paper, in direct contrast to documented fact, does not mean they were not exposed.
> 
> Your responses show EXACTLY why I teach Narcan to LE. You have already made up your mind that you know more than anyone else, and that all cops are liars.
> 
> ...



Dude, really?

First, just because a cop thinks they were exposed and used narcan doesn't mean they were actually exposed, so narcan deployment is not evidence of anything. Second, nothing that anyone said in this thread indicated that they would withhold narcan that was clinically indicated and "kill a cop". Lastly, the fact that you "teach narcan to LEO" doesn't make you an authority on the subject, and certainly does not make you more objective. 

So seriously, the histrionics are not necessary.


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## ParamagicFF (Oct 17, 2018)

Phillyrube said:


> Ok, watching Nightwatch on AETV.  First call, overdose.  Cool.  Get him in the box, O2, pulseox. EtCO2.,   Fire department bagging guy.  Start an IV, and "Narcan is in".  *Next second guy is up, with like 8 people trying to hold him down*.  Blood from the pulled out IV sprays everyone.   Finally guy calms down after being restrained every which way.
> 
> Sound familiar?  How do you handle it?   Our protocols call for 2-4 mg narcan IV or IN.  With the advent of CO2 monitoring, do we need to throw the entire dose on the patient?  We've been giving the patient 1-2 mg narcan, and monitor.  If the numbers are good, let them sleep.  Now, we gotta train the cops not to be so quick with their INs.  Had a couple get pissed cause the woke up the pateint, who is now combative, and I made them ride in with us (helps that I was also a PD supervisor).
> 
> ...



I wonder if the reason the guy panicked was because he woke up to 8 people holding him down? I would say I average between 1-2 narcan administrations per 24 hour shift at work. Our protocol for ALS or BLS is to give 2mg IM/IN for the unconscious heroin user regardless of respiratory effort. Regardless of personal feelings about the protocol or our local healthcare system strategies for these patients, it is how we handle these calls.

That being said, I have NEVER had a single patient wake up combative. I have literally seen hundreds of patients go from unresponsive to standing and talking, and not once have they been combative. They may be uncooperative, not wanting to talk to me or admit to drug use, but they are never combative. I've seen them get sick and vomit, have diarrhea, and shiver. There is also the characteristic long yawn. But I've never seen someone angry or violent.

Then again, we never try to restrain them physically. We support their respirations and oxygenation, and as they become rousable we give speak to them about the circumstances like we would a postictal patient. 90% of these patients end up refusing care either by listening to the informed consent speech, or by simply walking away and stating they don't want to deal with me anymore. The remaining 10% that accept transport are usually those that want to go get food.


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## ZombieEMT (Dec 20, 2018)

When Narcan first became available to BLS and PD, it was the standard 2mg kit that we had to assemble for IN administration. Generally we gave it, and I never had issues. Recently the 4mg doses became available that require no assembly. What happens is police get on location and they just keep pushing. Patients that might have gotten 4mg are now getting 8mg. Sometimes we are seeing police even giving up to 16mg, then our patients become agitation and vomit.


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## NPO (Dec 20, 2018)

ZombieEMT said:


> When Narcan first became available to BLS and PD, it was the standard 2mg kit that we had to assemble for IN administration. Generally we gave it, and I never had issues. Recently the 4mg doses became available that require no assembly. What happens is police get on location and they just keep pushing. Patients that might have gotten 4mg are now getting 8mg. Sometimes we are seeing police even giving up to 16mg, then our patients become agitation and vomit.


That's an education problem, not a supply problem.


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## Joshua Henson (Jan 2, 2019)

I don’t think Police should have this.


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## CCCSD (Jan 2, 2019)

Remi said:


> Dude, really?
> 
> First, just because a cop thinks they were exposed and used narcan doesn't mean they were actually exposed, so narcan deployment is not evidence of anything. Second, nothing that anyone said in this thread indicated that they would withhold narcan that was clinically indicated and "kill a cop". Lastly, the fact that you "teach narcan to LEO" doesn't make you an authority on the subject, and certainly does not make you more objective.
> 
> So seriously, the histrionics are not necessary.



Histrionics? No. Just real. If you weren’t there, and haven’t read the reports, then you needn’t make such a comment. I don’t know where you get your misinformation, I get weekly updates on exposures as part of my job.

It’s simply AMAZING that some paramedics are so well trained that they can diagnose from across the country, and their chemical analysis skills are so incredible that I don’t understand why we bother with narcotics dogs. 

So...based on how you think, if a patient told you they were bleeding, but you didn’t see anything, you would just blow them off, because you don’t feel that they know what’s happening to themselves, but you always know better, right?

Your fellows said they would withhold Natcan unless they felt it was needed, in this and other cases, just read the thread on Narcan use for PEA etc. 

I’m an quite versed in my role as a POST certified instructor, having written not only the EMS research paper, EMS Policy, and certification course, but I’ve spent hundreds of hours on research, application, and use.

Good Day.


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## CCCSD (Jan 2, 2019)

Joshua Henson said:


> I don’t think Police should have this.



Why? Because they are cops?


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## Carlos Danger (Jan 3, 2019)

CCCSD said:


> Histrionics? No. Just real.



his·tri·on·ic
/ˌhistrēˈänik/
_noun_
plural noun: *histrionics*

exaggerated dramatic behavior designed to attract attention.
synonyms: dramatics, theatrics, tantrums; More
Apparently I need to remind you:


CCCSD said:


> You have already made up your mind that you know more than anyone else, _and that all cops are liars._
> 
> So _when you do kill a cop because you felt Narcan wasn’t needed_, make sure you fess up to the family and all my Brothers and Sisters out there.






CCCSD said:


> If you weren’t there, and haven’t read the reports, then you needn’t make such a comment.



If I wasn't where? Seriously, what are you even talking about? The comment that made you fly off the handle was that administration of narcan is not itself evidence of exposure. Which is 100% true. That's basic reasoning. No one has suggested that naloxone is never needed in these cases.

I know paramedics who love to give narcotics, and use them way more than others in their system. Is that itself evidence that their patients have more pain? Of course not.



CCCSD said:


> So...based on how you think, if a patient told you they were bleeding, but you didn’t see anything, you would just blow them off, because you don’t feel that they know what’s happening to themselves, but you always know better, right?



Would I blow them off? No, of course not. I'd do an assessment. But if you are asking my whether I'd apply a tourniquet and pressure dressing to an extremity that shows no evidence whatsoever of hemorrhage, the answer is I would not. Would you?



CCCSD said:


> Your fellows said they would withhold Natcan unless they felt it was needed, in this and other cases, just read the thread on Narcan use for PEA etc.


Well yeah….that's exactly how medicine works. Interventions are provided as indicated….I don't give anyone anything that isn't indicated, just because they think they need it.

I don't instantly shock someone with a history of SVT just because they tell me their heart is racing….I put them on the monitor, do an assessment, and make a diagnosis. I don't slam 2mg of dilaudid into someone who walks up to me and tells me they need dilaudid because are in pain….I do an assessment and figure out the best drug and dose. I don't slam antibiotics into someone just because they tell me they haven't been feeling well. And lastly, no, I don't pump someone full of naloxone who is talking to me and not showing any signs of opioid intoxication, just because they tell me they were exposed.

The narcan use in PEA has nothing to do with this. Yes, I will give narcan to someone in PEA if I think opioids may be part of why they arrested. There's also the novel use of high doses of naloxone as a sympathetic agonist. Not sure how that's relevant here, but you brought it up.



CCCSD said:


> I’m an quite versed in my role as a POST certified instructor, having written not only the EMS research paper, EMS Policy, and certification course, but I’ve spent hundreds of hours on research, application, and use.



Very impressive. But I would expect someone with your academic credentials to have more respect for the type of published work that Tigger posted the link to, and not to get so emotional when people express alternative views based on reason.

If you want to educate us on the shortcomings of our understanding, please do. Pro tip: teaching and changing minds is much easier when you don't insult your audience and when you rely more on reason and published evidence than emotion.


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## DrParasite (Jan 3, 2019)

CCCSD said:


> Histrionics? No. Just real. If you weren’t there, and haven’t read the reports, then you needn’t make such a comment. I don’t know where you get your misinformation, I get weekly updates on exposures as part of my job.


So your reports are all validated by lab results, and reviewed by toxicologist (you know, experts in this type of stuff), before they get disseminated?  OR were they simply officer A was exposed to an opiate, was given narcan, and he is still with us and back on the job?  BTW, just because your "exposed" to an opiate, doesn't mean narcan is indicated.

But why don't you read the published and validated report from a known toxicologist?  It was published in Emergency Medicine News,and explains what actually happens. Oh, and that's coming from an actual expert, and regarded as a "brilliant clinical toxicologist."  I am pretty sure the authors of your weekly reports can't say the same.





CCCSD said:


> It’s simply AMAZING that some paramedics are so well trained that they can diagnose from across the country, and their chemical analysis skills are so incredible that I don’t understand why we bother with narcotics dogs..


Because a dog can sniff a narcotic, while most paramedics can't?  and just because a bloodhound catches a whiff of heroin, doesn't mean we need to give every cop preventative narcan, just in case.





CCCSD said:


> So...based on how you think, if a patient told you they were bleeding, but you didn’t see anything, you would just blow them off, because you don’t feel that they know what’s happening to themselves, but you always know better, right?


Ummm, if my patient is telling me they did heroin, than that chances are pretty good that they don't need narcan. 

Why do we give narcan again?  What are the indications?  Can you refresh my hose dragging brain?


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## Tigger (Jan 4, 2019)

CCCSD said:


> I’m an quite versed in my role as a POST certified instructor, having written not only the EMS research paper, EMS Policy, and certification course, but I’ve spent hundreds of hours on research, application, and use.
> 
> Good Day.


Could you post the paper and policy? What course?


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## bbrg548 (Dec 29, 2019)

StCEMT said:


> Narcan drip. NPA/EtCO2/NRB or BVM if ventilations are too low. **** around for a few minutes while EtCO2 and O2 sat returns to a happy place then start an IV. 2mg Narcan in 250cc. Titrate to effect just like D10.


Could you show us your protocol for this? We're redoing our protocols and I'd like to submit something similar for consideration, and something to use as a reference would be very helpful.


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## StCEMT (Dec 29, 2019)

bbrg548 said:


> Could you show us your protocol for this? We're redoing our protocols and I'd like to submit something similar for consideration, and something to use as a reference would be very helpful.


We don't actually have one specifically for it. Did it in response to almost getting kicked in the face.


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## NPO (Dec 29, 2019)

EMS World published an article about paramedics giving Suboxone or Subutex with narcan. Apparently New Jersey has added this in their state protocols.

I'm interested to hear some opinions from the wise and experienced people here.


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## GMCmedic (Dec 29, 2019)

NPO said:


> EMS World published an article about paramedics giving Suboxone or Subutex with narcan. Apparently New Jersey has added this in their state protocols.
> 
> I'm interested to hear some opinions from the wise and experienced people here.


I think its buprenorphine. Buprenorphine and narcan essentially make suboxone.


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## CCCSD (Dec 29, 2019)

DrParasite said:


> So your reports are all validated by lab results, and reviewed by toxicologist (you know, experts in this type of stuff), before they get disseminated?  OR were they simply officer A was exposed to an opiate, was given narcan, and he is still with us and back on the job?  BTW, just because your "exposed" to an opiate, doesn't mean narcan is indicated.
> 
> But why don't you read the published and validated report from a known toxicologist?  It was published in Emergency Medicine News,and explains what actually happens. Oh, and that's coming from an actual expert, and regarded as a "brilliant clinical toxicologist."  I am pretty sure the authors of your weekly reports can't say the same.Because a dog can sniff a narcotic, while most paramedics can't?  and just because a bloodhound catches a whiff of heroin, doesn't mean we need to give every cop preventative narcan, just in case.Ummm, if my patient is telling me they did heroin, than that chances are pretty good that they don't need narcan.
> 
> Why do we give narcan again?  What are the indications?  Can you refresh my hose dragging brain?



I’m not here to teach you what you should know. However, if you need a class, I’d be happy to set you up.


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## DrParasite (Dec 30, 2019)

CCCSD said:


> I’m not here to teach you what you should know. However, if you need a class, I’d be happy to set you up.


translation: you don't know, you're teaching bad information not based on actual medicine but on panic and hysteria, and when someone someone calls you out on it, you aren't able to back up your BS claims with actual facts or science.   but if I wanted, I could pay you to tell me all this incorrect information. 

I think I'll pass on your offer; thanks though.


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## hpclayto (Jan 22, 2020)

We issue it to all of our people. I don’t have a problem with it. I agree that the risk of exposure through daily operations is extremely small. If you can ask for narcan you don’t need narcan.  The majority of time we make scenes long before the fire department and are waiting 5-15 minutes for an ambulance. The negative effects of pushing too much too fast are minuscule as opposed to not giving it. It’s harmless, a lot easier to carry than a BVM and is a simple thing for patrol guys to give because the majority of cops are idiots when it comes to doing non cop things.


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## DrParasite (Jan 22, 2020)

hpclayto said:


> The negative effects of pushing too much too fast are minuscule as opposed to not giving it. It’s harmless, a lot easier to carry than a BVM and is a simple thing for patrol guys to give because the majority of cops are idiots when it comes to doing non cop things.


and it's great, until you come across an unconscious and apneic patient who either ODed on drugs other than opiods, or who didn't OD at all..... then you can give all the narcan you want, but the patient is still going to die.


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## NomadicMedic (Jan 22, 2020)

I've seen cops push Narcan on hypoglycemia and strokes. 

Stay classy.


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## Tigger (Jan 22, 2020)

I don't get too worked up if non-medical folks end up pushing narcan when it's not indicated. I have no reason to expect that law enforcement will ever have significant patient assessment or airway management skills, it's far from a law enforcement duty and the experience to be proficient is not likely obtainable. If they want to learn, awesome, I'll help them get better at that as best I can. But I don't expect it. The idea that we should just give everyone a BVM is just not a practical solution. 

Public use narcan will continue to expand. Inappropriate use will continue. But also, apneic opiate ODs will be reversed, and I'm cool with that trade. I'd prefer there be some suspicion of opiate OD at least, but I'm not gonna get too mad if it wasn't. A little on scene education might go a long way. 

If a cop narcans a hypoglycemic, the patient will remain hypoglycemic until the ambulance arrives, just like they would have without the narcan.


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## GMCmedic (Jan 23, 2020)

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