# What are you allowed to do?



## clibb (Dec 7, 2010)

What does your Medical Director allow you to do?

I work on ALS rigs as an EMT-B. I'm allowed to do all the basic medications such as Epinephrine, Glucose, ASA, Nitro, Oxygen, but we do not carry Acti-dose. As an IV certified EMT I'm also allowed to push D10, D25, and D50. Also in narcotic overdoses I'm allowed to push Narcan which is freaking sweet. Just recently we got extra training in King Tube intubation, so we are allowed to do that.
Plus any ALS assist that the Paramedic asks us to do. 

How about you guys?


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## usalsfyre (Dec 7, 2010)

Considering most of my past experinces with narcan, I disagree with how "freaking sweet" administering it is...


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## Shishkabob (Dec 7, 2010)

Anything my med control wants me to.


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## Amber2313 (Dec 7, 2010)

Hehe. We had a medic give narcan once for OD. Later, we heard him giving report. Pt was restrained, medic said he thought they'd be boxing. Then cutting out we heard, "Yep, we're gonna be boxing..." This came over the radio at the station while my basic class was in the next room.


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## TransportJockey (Dec 7, 2010)

In NM:
The following plus general FR skills like 02, CBG, splinting, etc...
a. Allowable Skills: 
1. Mechanical positive pressure ventilation.  
2. Use of multi-lumen, supraglottic, and laryngeal airway devices (examples: 
PTLA, Combi-tube, King Airway, LMA) 
3. Pneumatic anti-shock garment 
4. Application and use of semi-automatic defibrillators 
5. Acupressure 
6. Transport of patients with nasogastric tubes, urinary catheters, heparin/saline 
locks, PEG tubes, or vascular access devices intended for outpatient use 
b. Administration of approved medications via the following routes: 
1. Nebulized inhalation 
2. Subcutaneous 
3. Intramuscular 
4. Intranasal 
5. Oral (PO) 
c. Allowable Drugs 
1. Oral glucose preparations 
2. Aspirin PO for adults with suspected cardiac chest pain 
3. Activated charcoal PO 
4. Acetaminophen PO in pediatric patients with fever  
5. IM auto-injection of the following agents for treatment of chemical and/or nerve 
agent exposure: 
a. atropine 
b. pralidoxime 
6. Albuterol (including isomers), via inhaled administration 
7. Ipratropium, via inhaled administration, in combination with or after albuterol 
administration 
8. Epinephrine via auto-injection device 
9. Administration of naloxone by SQ, IM, or IN route 
10. Administration of Epinephrine, 1:1000, no single dose greater than 0.3 ml, 
subcutaneous or intramuscular injection with a pre-measured syringe or 0.3 ml 
TB syringe for anaphylaxis or status asthmaticus refractory to other treatments 
under on-line medical control.  When on-line medical control is unavailable, 
administration is allowed under off-line medical control if the licensed provider 
is working under medical direction using approved written medical protocols.

As an EMT-B IV/ECG in CO I could do similar to the OP. Never was a basic here in TX, but like Linuss said, anything the medical director says you can do.


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## clibb (Dec 7, 2010)

usalsfyre said:


> Considering most of my past experinces with narcan, I disagree with how "freaking sweet" administering it is...



O okay, then we disagree.

I totally forgot Albuterol. We are allowed to administer that. OPA and NPA.


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## medicRob (Dec 7, 2010)

My medical director is Dr. Kevorkian, so I can do everything. I can high-five people out of cardiac arrest, I can shock asystole, and about everything else you have seen on your favorite medical show.


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## usalsfyre (Dec 7, 2010)

clibb said:


> O okay, then we disagree.



Just a word of advice, "consciousness" is not a good end point goal of Narcan administration.

As Linuss and jt noted, Texas is an incredibly odd state regarding scope. Due to the delegated practice act, if a medical director want his ECAs (equivilent to a FR) doing open thoracotomies and cardiac massage, he's allowed to as long as he "adaquately trains" them. (Cant you see that CE. "After making the first inscion, you place the rib spreaders..."


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## lampnyter (Dec 7, 2010)

Medication wise i could adminster patients OWN epipen, nitro, inhaler. 5 Rights have to all be in place. And i could give glucose and charcoal. Thats it.


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## Amber2313 (Dec 7, 2010)

lampnyter said:


> Medication wise i could adminster patients OWN epipen, nitro, inhaler. 5 Rights have to all be in place. And i could give glucose and charcoal. Thats it.



Safe to assume O2 and ASA as well?

Same here, but random side note, my private carries charcoal. County 911 does not. Director says he won't waste money on it.


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## mgr22 (Dec 7, 2010)

clibb said:


> I'm allowed to push Narcan which is freaking sweet.



I have to admit, you're scaring me.


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## lampnyter (Dec 7, 2010)

ems.amber911 said:


> Safe to assume O2 and ASA as well?
> 
> Same here, but random side note, my private carries charcoal. County 911 does not. Director says he won't waste money on it.



No basics cant do aspirin


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## Amber2313 (Dec 7, 2010)

lampnyter said:


> No basics cant do aspirin



Really? Interesting. Where are you from? We can here in Indiana.


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## lightsandsirens5 (Dec 7, 2010)

usalsfyre said:


> Considering most of my past experinces with narcan, I disagree with how "freaking sweet" administering it is...



Yea, same here. The first time I saw it used, it was used improperly. I saw a cop get covered in puke, and I got involved in a wrestling match with the pt, another cop and a firefighter on the puke and urine soaked carpet. 

TITRATE!!! Only till they start to breathe spontaneously at an adequate rate. Not very cool in my opinion, but neither is FIVP Narcan. 

So maybe I disagree with you as well.


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## TransportJockey (Dec 7, 2010)

Never understood why people want to bother waking up a narc OD patient... Just get the RR up to normal or just bag them all the way to the hospital. It's not freaking rocket science. Just cause you CAN give the drug, doesn't mean you should.


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## lampnyter (Dec 7, 2010)

ems.amber911 said:


> Really? Interesting. Where are you from? We can here in Indiana.



Connecticut


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## usalsfyre (Dec 7, 2010)

jtpaintball70 said:


> Never understood why people want to bother waking up a narc OD patient... Just get the RR up to normal or just bag them all the way to the hospital. It's not freaking rocket science. Just cause you CAN give the drug, doesn't mean you should.



Because it's apparently "freaking sweet" don't ya know h34r: .


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## lampnyter (Dec 7, 2010)

[YOUTUBE]http://www.youtube.com/watch?v=8xU_vcb3kso[/YOUTUBE]

Narcan is friggen sweet!


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## lightsandsirens5 (Dec 7, 2010)

usalsfyre said:


> Because it's apparently "freaking sweet" don't ya know h34r: .




Yea you dummy! Some people........... READ THE THREAD!!!!!!!!!!

Jk y'alls.


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## Amber2313 (Dec 7, 2010)

lampnyter said:


> narcan is friggen sweet!



lmao!


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## lampnyter (Dec 7, 2010)

ems.amber911 said:


> lmao!



i love that movie


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## TransportJockey (Dec 7, 2010)

lampnyter said:


> [YOUTUBE]http://www.youtube.com/watch?v=8xU_vcb3kso[/YOUTUBE]
> 
> Narcan is friggen sweet!



Ah, that is one of my favorite scene of that movie


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## Amber2313 (Dec 7, 2010)

lampnyter said:


> i love that movie





jtpaintball70 said:


> Ah, that is one of my favorite scene of that movie



Never seen it, but seems to have good reviews and at least one good scene. Lol. Sunday night, here I come!


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## MedJPavlo (Dec 7, 2010)

ems.amber911 said:


> Never seen it, but seems to have good reviews and at least one good scene. Lol. Sunday night, here I come!


its such a dark movie. but its amazing. it really portrays how u can get burned out in this field


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## Veneficus (Dec 7, 2010)

usalsfyre said:


> Just a word of advice, "consciousness" is not a good end point goal of Narcan administration.
> 
> As Linuss and jt noted, Texas is an incredibly odd state regarding scope. Due to the delegated practice act, if a medical director want his ECAs (equivilent to a FR) doing open thoracotomies and cardiac massage, he's allowed to as long as he "adaquately trains" them. (Cant you see that CE. "After making the first inscion, you place the rib spreaders..."



Ohio was the same way until they went with state wide protocols. 

The old way was better.


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## abckidsmom (Dec 7, 2010)

lampnyter said:


> [YOUTUBE]http://www.youtube.com/watch?v=8xU_vcb3kso[/YOUTUBE]
> 
> Narcan is friggen sweet!



My dad did that once in a church with an unconscious diabetic.  Hand on the forehead, he said, "LORD, I ask you to HEAL this woman!" right about the time his partner had finished pushing the D50.


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## Amber2313 (Dec 7, 2010)

abckidsmom said:


> My dad did that once in a church with an unconscious diabetic.  Hand on the forehead, he said, "LORD, I ask you to HEAL this woman!" right about the time his partner had finished pushing the D50.



Holy water?


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## abckidsmom (Dec 7, 2010)

ems.amber911 said:


> Holy water?



Holy sugar water, I guess.


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## EMS49393 (Dec 7, 2010)

I agree to titrate narcan as well.  I have no desire to "raise I B Bangin'."

I understand narcan lowers the seizure threshold. That is really not fricken' sweet.


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## Shishkabob (Dec 7, 2010)

Veneficus said:


> Ohio was the same way until they went with state wide protocols.
> 
> The old way was better.




And really, that is how every state should be.  There should be a nation wide minimum which consists of the currently accepted standard of care, than the individual MC can choose to go above, but not below, the floor.


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## lightsandsirens5 (Dec 7, 2010)

Linuss said:


> And really, that is how every state should be.  There should be a nation wide minimum which consists of the currently accepted standard of care, than the individual MC can choose to go above, but not below, the floor.



WA is that way to a certain extent. But we are rapidly falling away from that. :-(


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## Shishkabob (Dec 7, 2010)

lightsandsirens5 said:


> WA is that way to a certain extent. But we are rapidly falling away from that. :-(



I hear rumors of Texas going that way... I will be a very very angry constituent if it does.


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## MrBrown (Dec 7, 2010)

Must we get into this argument again?

Brown feels bad chipping in coz it makes the rest of you look like crap

*Paramedic* 
Oxygen, OPA/NPA/LMA, methoxyflurane, entonox, semiautomatic and manual defibrilation, sync cardioversion, 3 and 12 lead ECG interpretation, IV cannulation incl EJ, aspirin, GTN, salbutamol, glucagon and oral glucose, IV glucose, adrenaline, naloxone, ondansetron, morphine

*Intensive Care Paramedic*
All of the above plus intubation, cricothyrotomy, pacingl, atropine, amiodarone, midazolam, ketamine, frusemide, rapid sequence intubation.

Frusemide is probably being withdrawn next year and thrombolysis is either here or being added depending on where you are.  Ceftriaxone, corticosteriods and clopridogel is also also here for some areas as well.


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## bstone (Dec 7, 2010)

I regularly do neurosurgey and acupuncture in the ambulance.


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## Shishkabob (Dec 7, 2010)

MrBrown said:


> Brown feels bad chipping in coz it makes the rest of you look like crap
> 
> *Paramedic*
> Oxygen, OPA/NPA/LMA, methoxyflurane, entonox, semiautomatic and manual defibrilation, sync cardioversion, 3 and 12 lead ECG interpretation, IV cannulation incl EJ, aspirin, GTN, salbutamol, glucagon and oral glucose, IV glucose, adrenaline, naloxone, ondansetron, morphine
> ...




Really?  Make us look like crap because of a few skills?  Aren't you one to claim "skills mean nothing"?  

If I wanted to, I could write out every skill and drug that is the norm at my agency, and it would trump your list.




So do you REALLY want to compare skills?  Hell, I'll win right now and state that if my doc wants me to do open heart surgery or an emergency in-field caesarean, I can legally.  (Ethically is another question completely)



(Smiley face to show friendliness   )


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## MrBrown (Dec 8, 2010)

Sorry mate, Brown forget to mention it takes four years to become a Paramedic here and six or seven to become an Intensive Care Paramedic.

No disrespect intended.


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## jrm818 (Dec 8, 2010)

MrBrown said:


> Must we get into this argument again?
> 
> Brown feels bad chipping in coz it makes the rest of you look like crap
> 
> ...



That last one surprises me.  How are you deciding which patients are candidates for plavix?


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## Veneficus (Dec 8, 2010)

jrm818 said:


> That last one surprises me.  How are you deciding which patients are candidates for plavix?



Patient is part of modern society?


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## jjesusfreak01 (Dec 8, 2010)

MrBrown said:


> Must we get into this argument again?
> 
> Brown feels bad chipping in coz it makes the rest of you look like crap
> 
> ...



*EMT*
Oxygen, OPA/NPA/BIAD, automatic defibrillation, 3 and 12 lead application, aspirin, GTN, albuterol, oral glucose, adrenaline, naloxone, any OTC meds our MC lets us play with (Tylenol, Benadryl, Tums, etc), and I cant forget, band-aids.


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## jjesusfreak01 (Dec 8, 2010)

Veneficus said:


> Patient is part of modern society?



Nah...patient is American


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## jrm818 (Dec 8, 2010)

Veneficus said:


> Patient is part of modern society?



AND has good health insurance or a large bank account....


I was under the impression that there was only a benefit to plavix in the highest risk group of patients, and that troponins were needed to determine that risk stratification.  Has it become common practice to hand it out more liberally?


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## Pittma (Dec 8, 2010)

MrBrown said:


> Sorry mate, Brown forget to mention it takes four years to become a Paramedic here and six or seven to become an Intensive Care Paramedic.
> 
> No disrespect intended.



So, does that mean the pay is decent, if you don't mind me asking?


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## Veneficus (Dec 8, 2010)

jrm818 said:


> AND has good health insurance or a large bank account....
> 
> 
> I was under the impression that there was only a benefit to plavix in the highest risk group of patients, and that troponins were needed to determine that risk stratification.  Has it become common practice to hand it out more liberally?



Given the rate at which it is prescribed and the amount of self referral I see among cardiologists for a prescription, I can't imagine that it wasn't always handed out rather liberally.


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## jrm818 (Dec 8, 2010)

Veneficus said:


> Given the rate at which it is prescribed and the amount of self referral I see among cardiologists for a prescription, I can't imagine that it wasn't always handed out rather liberally.



It is one of the top selling drugs in the US, so I suppose that I shouldn't really be surprised.  Of course I really have no real exposure to this medication other than the small bit that I've read, but what I've seen doesn't seem to me to demonstrate enough benefit to make this a "super drug."  I'm sure marketing has nothing to do with it of course.....

I don't know really anything about long term prophylaxis (which I imagine is a lot of what you see), but in terms of acute administration for ACS, I was pretty sure that only a rather limited cohort of patients would benefit. 

I just looked at the big CURE trial published in the NEJM, and I did misremember the criteria for inclusion, expanding a bit the population in which some benefit may have been demonstrated.

I had remembered  that in addition to ECG changes there must be elevated troponin for inclusion (thus my surprise that it was being given prehospitally, when troponin presumably could not be determined), but it turns out that the presence of either was sufficient.  I'm still curious about the criteria Brownland ambulances are using.

Apparently with a less rigorous screening scheme only harm was found.  I didn't think there had been a subsequent expansion of the population in which benefit was found, but I wouldn't be at all surprised to be proven wrong.


Is anyone else giving plavix in the prehospital arena?


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## emt_irl (Dec 8, 2010)

over in ireland we have no med control.
i have my own licence to practice which currently sits at emt level.
and i can decide what route of care i need to take, we have  clinical practice guidelines to follow set out by our national ems regulator.

i can admin 10 drugs (oxygen, salbutamol, asprin, gtn, glucose gel, glucogon im, entanox, paracetamol, epi pens) and then since were trianed to do i.m injections a doctor or someone higher qualified then us e.g paramedic or advanced paramedic can tell us to admin any other i.m drug.

I can do 3 lead ecg monitoring and rythm recognition, semi auto defib and all the usual bls stuff like bvm's and opa's. etc
emergency child birth and neonatal resus/care, 
then the usual things like spinal immoblisation, wound care and fracture care etc etc
we also do an emergency driving standard course, a radio opperations course and mass casuality training using the triage sort using cruciforms or coloured tape.

thats all i can think of off the top of my head, the rest that i cant think of is stuff we'd never realisticially use.


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## NomadicMedic (Dec 8, 2010)

jrm818 said:


> Is anyone else giving plavix in the prehospital arena?



Yes. Several counties in Washington State have now added Plavix (along with Heparin, Nitro drips and Tenecteplase) to the STEMI protocol.


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## MrBrown (Dec 8, 2010)

Pittma said:


> So, does that mean the pay is decent, if you don't mind me asking?



Nah the pay is not that good .... $50k NZ for a Paramedic and $60k for an Intensive Care Paramedic is about right .... tax is 21.9c on the dolllar


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## jrm818 (Dec 8, 2010)

n7lxi said:


> Yes. Several counties in Washington State have now added Plavix (along with Heparin, Nitro drips and Tenecteplase) to the STEMI protocol.



Interesting.  If you happen to know, are these mostly outlying areas with extremly long time to ED?  Are they transporting direct to PCI capable facilities?

I guess maybe I need to do some more plavix reading...


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## NomadicMedic (Dec 9, 2010)

jrm818 said:


> Interesting.  If you happen to know, are these mostly outlying areas with extremly long time to ED?  Are they transporting direct to PCI capable facilities?
> 
> I guess maybe I need to do some more plavix reading...



Yes. One agency I work for has a routine transport time of at least 45 minutes to a cath lab. Here, after a consult with OLMC, we can open the "Stemi Kit" and get at all of the above mentioned items. I was hoping I could find a copy of the protocols online to post here... but no luck yet.


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## Jay (Dec 10, 2010)

usalsfyre said:


> Considering most of my past experinces with narcan, I disagree with how "freaking sweet" administering it is...



Ironic as I was thinking the same exact thing. I was even talking to a medic recently who starts pushing at just 0.4 to avoid vagal stimulation affecting the puke reflex, if still no luck, 1mg thereafter. One of the smartest things I heard in a while.


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## Shishkabob (Dec 10, 2010)

Jay said:


> pushing at just 0.4 to avoid vagal stimulation affecting the puke reflex,



Errr.... what?


It's more to prevent the sudden and violent withdrawal symptoms, such as seizures and combativeness.


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## reaper (Dec 10, 2010)

It is for both reasons!


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## usalsfyre (Dec 10, 2010)

I haven't used narcan in literally years. Part of it is the area (more meth and mixed ODs rather than just straight narcotics) and some of it is the nasitness associated with Narcan. Most of the time an NPA, a little suction, some O2 and the occasional gentle stimulation to breathe is all that's needed. No puking, combativness, seizures, pulmonary edema, ect with this method.


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## Shishkabob (Dec 10, 2010)

usalsfyre said:


> I haven't used narcan in literally years. Part of it is the area (more meth and mixed ODs rather than just straight narcotics) and some of it is the nasitness associated with Narcan. Most of the time an NPA, a little suction, some O2 and the occasional gentle stimulation to breathe is all that's needed. No puking, combativness, seizures, pulmonary edema, ect with this method.





Do we have much PCP out here too, or is that more of a Dallas thing?


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## usalsfyre (Dec 10, 2010)

Linuss said:


> Do we have much PCP out here too, or is that more of a Dallas thing?



You see a smidgen of it in the area your going to but it's really spillover from the metroplex. East Texas is mostly meth, crack, benzos, "hillbilly heroin" (perscription opiates) and good old fashioned ethyl alcohol.


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## TransportJockey (Dec 10, 2010)

usalsfyre said:


> You see a smidgen of it in the area your going to but it's really spillover from the metroplex. East Texas is mostly meth, crack, benzos, "hillbilly heroin" (perscription opiates) and good old fashioned ethyl alcohol.



Funny, here in W. TX we have all of that except meth... Lots and lots of Benzo ODs though.


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## MrBrown (Dec 10, 2010)

We carry naloxone but Brown would not say its popular per-se and has never seen it used.  

In Browns mind there is more benefit in focusing on adequate support of oxygenation and circulation rather than waking people up, having them spew up on you and then have a seizure.

Perhaps naloxone is the next frusemide?


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## firecoins (Dec 10, 2010)

pushing just enough narcan is freaking sweet...just enough to bring back respitory function. I think breathing is freaking sweet. Anything more than that, narcan isn't needed.


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## jjesusfreak01 (Dec 10, 2010)

MrBrown said:


> Perhaps naloxone is the next frusemide?



Nah, it will stick around. Medics can titrate to get respiration back without waking pts up, and I don't think I'm the biggest fan of leaving someone in respiratory arrest just to avoid waking them. Sure, you can breathe for them, but I feel like that's just bad medicine.


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## boingo (Dec 10, 2010)

We give Narcan by the bucket full.  We don't see any meth, mostly heroin, crack and alcohol.


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## usalsfyre (Dec 10, 2010)

Many of these patients aren't actually apenic though, they're just "not breathing enough". Keeping them talking (talking requires ventilation) and gentle but firm stimulation when needed will usually keep them awake enough that no naloxene is needed.

If they're truly out though, by all means go for the narcan.


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