# Narcan



## trauma1534 (Nov 16, 2006)

I am curious as to how different providers would handle this.  You have a methidone overdose.  Or with any overdose for that matter... which would you do and why?  This particular patient was 40yom, resp. 4, unresponsive.  

A.  Give enough narcan to increase resp drive, transport

B.  Intubate, give some narcan

C.  Don't intubate, give narcan and wake up patient, transport (tx done enroute)


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## jeepmedic (Nov 16, 2006)

Give Narcan get refusal signed go back  base and go to bed.    :lol: 


Not really but is good for a laugh. I would give enough Narcan to improve respitory rate then transport and keep an eye on resp. rate and keep it around 12 to 14. You have to remember that sometimes the overdose is done in an attempt to kill themselves so you  have to be careful when wakeing them up.


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## Ridryder911 (Nov 16, 2006)

Our new medical director just had a discussion in regards to this question. i agree with him, just enough to improve respiratory drive. 

Recent studies have demonstrated seizures and sudden withdraw symptoms are being more and more reported by standard dose of 2 mg. Titration doses of 0.4mg SIVP, and watch effects of respiratory is the main purpose. If you notice increase respiratory drive, then you know your etiology and Dx. and one does not need to supercede. 

There are so many patients nowadays that are on narcotics, and diazepam type directives, one may not be aware of. Sudden withdraw with seizures, will be difficult to control after administering antagonist medications. 

R/r 911


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## FFEMT1764 (Nov 17, 2006)

I, too, would have to agree with the others here. If you give them more than enough needed to increase repiratory effort and improve SPO2 you run the risk of the seizures, as well as having a full blown fight in the back of the little white box.


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## KEVD18 (Nov 17, 2006)

while enroute:
just enough to increase and stabalize resp drive.

immediatley upon arrival at recieving H(still in rig in lot):
enough to wake em up, ruin the best high of their life, piss em off. then you walk in, point to the nurse you dont like and say" she did it"


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## fyrdog (Nov 17, 2006)

I would go with anser A. Just enough to increase resps. A BLS airway is temporarily acceptable if it provides O2 for perfusion. I wouldn't feel to bad if they woke up but no need to fight with them or make them puke. 

There are very few occurances of a PT going into withdrawl and then into v-fib but only when too much Narcan is pushed too fast.  It's rare but documented.


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## oldschoolmedic (Nov 17, 2006)

Do you know upfront that it is a methadone OD, or is this what you find out after the fact? Like being dispatched to a "unresponsive male." The reason I ask is because with resps that slow and no history to go on, this guy buys a tube until I can do a better exam. Our med control would eat me alive for not tubing this guy, securing the airway first. After finding out this was an OD then we could extubate and narcan him, depending on the doc's feeling at that second and whether the planets had aligned as he wished, but you know how that goes. But eliminating all of the "what ifs" I would go with titrating narcan to respiratory drive (answer A)


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## Medivixen (Nov 18, 2006)

D: follow local protocols


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## MICU (Nov 18, 2006)

Medivixen said:


> D: follow local protocols



Right there with you


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## Airwaygoddess (Nov 19, 2006)

DITTO:excl:


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## RescueRandy (Nov 20, 2006)

oldschoolmedic said:


> Do you know upfront that it is a methadone OD, or is this what you find out after the fact? Like being dispatched to a "unresponsive male." The reason I ask is because with resps that slow and no history to go on, this guy buys a tube until I can do a better exam. Our med control would eat me alive for not tubing this guy, securing the airway first. After finding out this was an OD then we could extubate and narcan him, depending on the doc's feeling at that second and whether the planets had aligned as he wished, but you know how that goes. But eliminating all of the "what ifs" I would go with titrating narcan to respiratory drive (answer A)



I'd have to ask: have you done this? Tubed and then gave narcan? Really it's a great textbook answer but does't work in reality. You give the narcan first, it's fast and easy, then you KNOW what the problem is. It's harmless enough at a dose less than 2 mg and sure is a lot better for everyone.

I've worked at a couple of services over the last 20 years and it's always been a standing type order, so the medical control is not even involved until down the road.

But of course I understand every place is different.


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## Ridryder911 (Nov 20, 2006)

oldschoolmedic said:


> Do you know upfront that it is a methadone OD, or is this what you find out after the fact? Like being dispatched to a "unresponsive male." The reason I ask is because with resps that slow and no history to go on, this guy buys a tube until I can do a better exam. Our med control would eat me alive for not tubing this guy, securing the airway first. After finding out this was an OD then we could extubate and narcan him, depending on the doc's feeling at that second and whether the planets had aligned as he wished, but you know how that goes. But eliminating all of the "what ifs" I would go with titrating narcan to respiratory drive (answer A)



I disagree with intubating initially also. Treat the etiology not the symptoms. As well, now you have a person that awakens on a vent (traumatic event)... and  now you either can will have to extubate (which is also traumatic). 
K I S S Keep it safe and simple.. one should be able to control an airway for at least 3 minutes and ventilate properly until Narcan can be administered to increase respiratory drive. 

R/r 911


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## Fedmedic (Nov 22, 2006)

I can't tell you what I would really do, yall would laugh at me...oh well...you know me though...you can about imagine.


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## trauma1534 (Nov 22, 2006)

This was a known meth od.  

Fed, really what would you do? LOL


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## jeepmedic (Nov 22, 2006)

trauma1534 said:


> This was a known meth od.
> 
> Fed, really what would you do? LOL



I know I know


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## Jon (Nov 22, 2006)

I'd titrate narcan to effect, ie: normal resp. rate. For the first few minutes, I'd have my partner ventilate the patient correctly with a BVM and perhaps an airway (probably nasal). As their respiratory drive comes back, switch them over to 100% O2 by NRBM and transport. Make sure your IV is taped down well in case they wake up and are unhappy.

If you tube the guy, he wakes up and tries to yank the tube - BAD
If you give 2mg of Narcan and wake the guy up suddenly - BAD
If you feel like being a PITA to the patient and are burned out, and sick of the skells who take a little too much heroin - give 2mg IM, then 2mg IVP - that wakes them up and keeps them up, for a while... (this is REALLY BAD... don't do this) - this is how Philly FD EMS put it to me.


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## trauma1534 (Nov 22, 2006)

what about... tube them... start the line, give them enough narcan to wake them up, then extubate them, get them to sign your refusal, if they won't sign, then get PD to witness, then you are back in service=back on the couch=down time!!!  Sound good???  lol


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## Ridryder911 (Nov 23, 2006)

Sounds good to me!.. as long as they can make it alive until post shift change...LOL

R/r 911


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## Jon (Nov 24, 2006)

My concern is that there isn't always a field extubation protocol.


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## jeepmedic (Nov 24, 2006)

trauma1534 said:


> what about... tube them... start the line, give them enough narcan to wake them up, then extubate them, get them to sign your refusal, if they won't sign, then get PD to witness, then you are back in service=back on the couch=down time!!!  Sound good???  lol




You forgot saving the taxpayers money. So we can put more trucks on the road and give us more down time.


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## trauma1534 (Nov 24, 2006)

Oh yeah Jeep and if the money saved by the tax payers does not put more trucks on the road, then maybe it will save enough to send more providers to the annual EMS Symposuim where we can become more educated on those finer things in life...


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## jeepmedic (Nov 24, 2006)

trauma1534 said:


> Oh yeah Jeep and if the money saved by the tax payers does not put more trucks on the road, then maybe it will save enough to send more providers to the annual EMS Symposuim where we can become more educated on those finer things in life...



Like promethazine admin.


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## trauma1534 (Nov 24, 2006)

and IV practice on eachother!  LOL


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## eggshen (Nov 25, 2006)

Anybody out there using intranasal narcan?

Egg


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## Fedmedic (Nov 25, 2006)

eggshen said:


> Anybody out there using intranasal narcan?
> 
> Egg



I think that was what they used on me the last time I OD'd on heroin....I think.


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## trauma1534 (Nov 26, 2006)

Oh Fed, did I steal your tx plan for this situation?  LOL


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## Fedmedic (Nov 26, 2006)

trauma1534 said:


> Oh Fed, did I steal your tx plan for this situation?  LOL



Who me? Would I do something like that?


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## Fedmedic (Nov 26, 2006)

I wonder if narcan works on Motrin and Maalox overdoses? Hmmmmm........

Probably not, therefore you know I couldn't have done anything like that...could I?


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## trauma1534 (Nov 26, 2006)

Fedmedic said:


> Who me? Would I do something like that?



ya think?  LOL


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## Guardian (Nov 26, 2006)

we got a lot of people from Virginia on here, I got family in Va, what part of Va yall from?


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## jeepmedic (Nov 26, 2006)

southern Va.


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## jeepmedic (Nov 26, 2006)

Fedmedic said:


> Who me? Would I do something like that?



Press Hard 2 Copy's


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## Fedmedic (Nov 26, 2006)

South central Virginia


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## trauma1534 (Nov 26, 2006)

Fedmedic said:


> South central Virginia



I too am from South Central Virginia


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## trauma1534 (Nov 26, 2006)

Guardian said:


> we got a lot of people from Virginia on here, I got family in Va, what part of Va yall from?



Where is your family from in VA?


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## Guardian (Nov 27, 2006)

Triangle, Va


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## trauma1534 (Nov 27, 2006)

Guardian said:


> Triangle, Va




I'm not sure where that is.  Where is it close to?


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## jeepmedic (Nov 27, 2006)

Hey its out near Quantico. Look at a map once and awhile


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## trauma1534 (Nov 27, 2006)

jeepmedic said:


> Hey its out near Quantico. Look at a map once and awhile



duh... I don't know how~

I can't read maps.  Maybe I need to go back to college and take up map reading major!


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## jeepmedic (Nov 27, 2006)

You went to college?


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## MeckRS83 (Nov 27, 2006)

trauma1534 said:


> duh... I don't know how~
> 
> I can't read maps.  Maybe I need to go back to college and take up map reading major!




Getting an education is not anything one should make light of, however they should strive for excelence in the highest level of education they an acheive, especially when trying to call themselves saving lives.  

EMS is a messed up system.  I think one should have atlease a Bachler's degree to be able to provide patient care in any field.  There should not be all these different levels.  We should just have one level and that's it.  A BS-Paramedic at a min.  With CC.  

In order to teach, one should possess a Master's degree when dealing with teaching meds and saving lives.


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## trauma1534 (Nov 27, 2006)

MeckRS83 said:


> Getting an education is not anything one should make light of, however they should strive for excelence in the highest level of education they an acheive, especially when trying to call themselves saving lives.
> 
> EMS is a messed up system.  I think one should have atlease a Bachler's degree to be able to provide patient care in any field.  There should not be all these different levels.  We should just have one level and that's it.  A BS-Paramedic at a min.  With CC.
> 
> In order to teach, one should possess a Master's degree when dealing with teaching meds and saving lives.



Ok.. now that is pushing it too far!!!  Alot of great providers in EMS don't have the means to recieve that much education.  We already have to get more recert time than RN's!  And they have master's!  All they have to do to keep thier license is to pay a fee and there you have it.  No con-ed or anything.  How do they keep up on the latest?

That idea is just pure out crazy!  We would loose most of our really good providers that way.  We definatly would not have any instructors left! 

When the states or agencies can start funding such educations, then maybe we can talk.  Until then, make the best of what we have.  EMS does alot for patients in the pre-hospital setting, just like it is today!


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## MeckRS83 (Nov 27, 2006)

How is it pushing it too far when all I am saying is that we need to raise the standards and then we won't have Mr. Joe Blow calling himself an EMT setting in the back of the truck in bib overhauls with tobacco stains in the corners of his mouth, calling himself providing patient care with a 4th grade education.  Do you know that you don't even have to have a high school deploma to be an EMT-B?


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## trauma1534 (Nov 27, 2006)

MeckRS83 said:


> How is it pushing it too far when all I am saying is that we need to raise the standards and then we won't have Mr. Joe Blow calling himself an EMT setting in the back of the truck in bib overhauls with tobacco stains in the corners of his mouth, calling himself providing patient care with a 4th grade education.  Do you know that you don't even have to have a high school deploma to be an EMT-B?



Well, I'll tell you one thing, some of those 4th grade educated, tobacco spitting, bib overhaul wearing EMT's are sharp!  You don't have to have a degree to have common since!  Heck, sometimes I'd be just as happy with Joe Blow in my truck assisting me than to have the highest medic in the state with a big head.  Joe Blow will set up my line without an argument.  Joe Blow will assess vitals for me when I am working on other things.  Joe Blow is willing to help.  Mr. Paragod is there just to show me how much he knows not to treat that patient.


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## Jon (Nov 27, 2006)

To Change the topic... I had an OD this weekend... medic gave him 2mg of Narcan, and he started breathing again... what a wonderful thing


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## MeckRS83 (Nov 27, 2006)

Jon said:


> To Change the topic... I had an OD this weekend... medic gave him 2mg of Narcan, and he started breathing again... what a wonderful thing




Obviously he had not really stopped breathing all together.  Narcan is a wonderful drug.  But, I disagree with giving the who 2 of Narcan.  You titrate to resp. improvement.


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## Jon (Nov 27, 2006)

MeckRS83 said:


> Obviously he had not really stopped breathing all together. Narcan is a wonderful drug. But, I disagree with giving the who 2 of Narcan. You titrate to resp. improvement.


Oh... He'd stopped breathing. He had a resp. rate of 0 and was tolerating an oral airway well - until the medic woke him and he spit it out.

As for the speed and amount... I know what you are saying, but I'm not an EMT-P... the medic gave it as a somewhat-slow IV Push... The patient slowly woke up, then sat up, and was very unhappy that we'd cut his shirt off. He also didn't want to go to the hospital, because "he didn't remember not breathing"


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## trauma1534 (Nov 27, 2006)

Jon said:


> Oh... He'd stopped breathing. He had a resp. rate of 0 and was tolerating an oral airway well - until the medic woke him and he spit it out.
> 
> As for the speed and amount... I know what you are saying, but I'm not an EMT-P... the medic gave it as a somewhat-slow IV Push... The patient slowly woke up, then sat up, and was very unhappy that we'd cut his shirt off. He also didn't want to go to the hospital, because "he didn't remember not breathing"




Go figure!  LOL  Pissed because you cut his shirt off!  You know what you could have done then... told him to press hard, 3 copys!  Treat and release baby!!


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## FFEMT1764 (Nov 28, 2006)

trauma1534 said:


> Go figure! LOL Pissed because you cut his shirt off! You know what you could have done then... told him to press hard, 3 copys! Treat and release baby!!


 
Can't do that here, once you give the Narcan they go to the ER. Anyone who OD's has to go to the ER, they lose the chance to decide for themselves. The only 2 drugs we can give someone and then waiver are D50 and albuterol. Everyone else who gets meds goes to the ER. Period. OD's that dont want to go get EPC'd and then get the ambulance ride.


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## trauma1534 (Nov 28, 2006)

FFEMT1764 said:


> Can't do that here, once you give the Narcan they go to the ER. Anyone who OD's has to go to the ER, they lose the chance to decide for themselves. The only 2 drugs we can give someone and then waiver are D50 and albuterol. Everyone else who gets meds goes to the ER. Period. OD's that dont want to go get EPC'd and then get the ambulance ride.




Then good luck on your lawsuit if someone refuses transport and you take them anyway!  Does the term Kidnap mean ring a bell?


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## FFEMT1764 (Nov 28, 2006)

In SC if you overdose the law says you are no longer able to make competent decisions, and we can take someone against their will. We always have SO on scene for OD's, and if needed the we ask them to place the individual in Emergency Protective Custody, and then we transport them, once in custody they also lose the right to choose what they do.


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## jeepmedic (Nov 28, 2006)

FFEMT1764 said:


> In SC if you overdose the law says you are no longer able to make competent decisions, and we can take someone against their will. We always have SO on scene for OD's, and if needed the we ask them to place the individual in Emergency Protective Custody, and then we transport them, once in custody they also lose the right to choose what they do.



I don't know about South Carolina law but in the Federal System even Inmates have the right to refuse any and all treatment.

You have woken them up they are A&O x 4 then they  have the right to refuse. If you take them then it is false imprisonment. If you touch them it is Battery. If you threaten them it is Assualt.

If you have them EPCed then the county is responsable for there medical bills. And this day and time of budget troubles the EPC's are becoming less and less. If the pt. is compantant then most law enforcement angency's are not going to arrest someone just so you can take them to the ED. You have to have a reason like the Pt. stateing that they tried to kill themselves, they have drugs on them, or something like that. Is this right I don't make the laws so I don't know. I just do what is in the best intrest of my Dept. and myself and that is *try* to do what is best for my Pt. If I can talk the Pt. into going to the ED then great thats what will happen if I can't I try again. I look for ways to make the LEO to place them into PC. If all fails ask the Pt. what Funeral Home the request because that mybe the one that comes back to pick them up. This sometimes works, but sometimes it doesn't.


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## FFEMT1764 (Nov 28, 2006)

I see your point, and respect it, and that is why I personally don't give the narcan until I am already enroute. That way when they wake up we are at the ER and then they can refuse in the ER if they want. The whole OD thing is that if they took the OD then they tried to harm themselves, and here in SC it is against the law to attempt suicide...though it's legal if you succeed...go figure...

Of course to add to the whacky laws on the books here on Wednesday at noon you can take your wife to the courthouse steps and beat her in public...still legal in the law books but I wouldn't want to try it and see if the PD upholds that law.


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## jeepmedic (Nov 28, 2006)

FFEMT1764 said:


> I see your point, and respect it, and that is why *I personally don't give the narcan until I am already enroute. That way when they wake up we are at the ER *and then they can refuse in the ER if they want. The whole OD thing is that if they took the OD then they tried to harm themselves, and here in SC it is against the law to attempt suicide...though it's legal if you succeed...go figure...
> 
> Of course to add to the whacky laws on the books here on Wednesday at noon you can take your wife to the courthouse steps and beat her in public...still legal in the law books but I wouldn't want to try it and see if the PD upholds that law.



This has been my practice. It keeps me out of the funny papers. 

Now as far as the OD thing. We had a Pt that had ODed on narcotics that were prescribed for pain. He did not mean to do it but he had brain CA and could not remember taking them, so he took more.


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## FFEMT1764 (Nov 28, 2006)

jeepmedic said:


> Now as far as the OD thing. We had a Pt that had ODed on narcotics that were prescribed for pain. He did not mean to do it but he had brain CA and could not remember taking them, so he took more.


 
In that particular instance I would still want to transport the gentleman to the ED just so they could evaluate him for a different med, and maybe get him some home health to admin his meds so he doesnt have to worry about remembering them all the time.


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## jeepmedic (Nov 28, 2006)

FFEMT1764 said:


> In that particular instance I would still want to transport the gentleman to the ED just so they could evaluate him for a different med, and maybe get him some home health to admin his meds so he doesnt have to worry about remembering them all the time.



We did and also contacted his CA Dr. and it all worked out.


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## FFEMT1764 (Nov 28, 2006)

That good. The good things that come from our work are what keep us all involved in EMS, as it is certainly not the pay!


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## Jon (Nov 28, 2006)

My guy got the "go with us, or go with them (PD)" speech... that, and the danwing realization that his life had just been saved by the SAME medic that did it over the summer when he <PROPBABLY> took Fentinyl Heroin.... he thought going would be a good idea after all.


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## FFEMT1764 (Nov 28, 2006)

Yep, gotta love repeat offenders!


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## jeepmedic (Nov 29, 2006)

Jon said:


> My guy got the "go with us, or go with them (PD)" speech... that, and the danwing realization that his life had just been saved by the SAME medic that did it over the summer when he <PROPBABLY> took Fentinyl Heroin.... he thought going would be a good idea after all.



I have heard that the going thing now is to get used Fentinyl patches and cut them up separate them then take whats left of the medication SL. Anyone else heard this?


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## Ridryder911 (Nov 29, 2006)

Actually JEMS had an article on this a while back. As well as Hospice has had problems of people stealing med.'s etc.. and watching the obituaries to get the med.s if they are not picked up... tack and sick. 

R/r 911


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## Anomalous (Nov 29, 2006)

jeepmedic said:


> I have heard that the going thing now is to get used Fentinyl patches and cut them up separate them then take whats left of the medication SL. Anyone else heard this?



I've also heard it's common to carry your own Narcan.  Just made sure your buddy can use it and you are back in the party with little or no down time.  I don't suppose we can bill them if they use their own.


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## jeepmedic (Nov 29, 2006)

Anomalous said:


> I've also heard it's common to carry your own Narcan.  Just made sure your buddy can use it and you are back in the party with little or no down time.  I don't suppose we can bill them if they use their own.



Now I haven't heard that one


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## FFEMT1764 (Nov 30, 2006)

I havent heard that either...my question is where are these people getting narcan on the street- you have yo order it from a med supply company I thought, and then only with a script, and someone has to sign for hte delivery. Its not like CVS is stocking narcan.


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## Jon (Nov 30, 2006)

Anomalous said:


> I've also heard it's common to carry your own Narcan.  Just made sure your buddy can use it and you are back in the party with little or no down time.  I don't suppose we can bill them if they use their own.


I've not heard it was common, but I've heard of users having it... I'm not sure how they get it, though.


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