Intranasal Narcan for BLS

[systemet]

Also, when you are dealing with a tax base of 1500 people, how much of a non-noticable tax increase would actually effectively fund a full time EMS service?

This is a point that is often missed in the discussion when considering US systems (and is also relevant in some parts of Canada). If EMS is a municipally funded entity, there's a great disparity in how much resources different communities have to direct towards it.

In many other countries EMS is a federally funded public service. This changes the variables a lot.

Actually, the majority of people around here don't have health insurance. Your 2.75% tax increase would almost double our current sales tax rate of 7%, taking sales taxes as an example.

Well, technically that would be increasing it by less than 50%. However, this whole discussion is making a bunch of assumptions.

US healthcare is (I think) the most expensive per capita in the world, and about the only system in an industrialised country that doesn't universally insure. If (and this one big, if, because there's a lot of vested interests opposing this), it was restructured towards a European system, it might cost a lot lot less.

If the Australians pay a 2.5% sales tax towards healthcare (I think this might actual be a payroll/income tax, perhaps someone can clarify), I'm sure the cost of insuring the currently uninsured would be less than the cost of reproducing the entire Australian healthcare system.

Also, in a global context, a 7.5% sales tax is pretty low. For example:

Canada - has provincial and federal sales tax, varies by province from 5-15%
Australia - 10%
Sweden - 25% (also the employer pays a 31% payroll tax!)
UK - 20% (a little over 10 years ago this was "only" 15%)
New Zealand - 15%
Norway 25%
South Africa - 14%
France - ~ 20%
Germany - 19%
Mexico - 16%

[Most countries have a lower rate on transportation costs, or on supermarket food items, children's clothes, etc.]

Part what's being missed in the fiscal responsibility debate in the states, is the choice not to tax is a choice not to collect revenue. Tax cuts have the same result as spending. Also, it's not like the US budget isn't actually quite large. If money was redistributed from defense spending, it might easily cover healthcare reform.

Then you don't understand how America works. People are free to make their own choices, even if you believe it is the wrong one. No amount of explaining it will change everyone's mind.

Yeah, because the US is so different from any other democratic nation on the planet? The US is intrinsically different and "more free" than Canada, the UK, New Zealand, Australia, France, Germany, Italy, Spain, Portugal, Sweden, Norway etc. Those are all police states like Syria or North Korea where dissent is brutally crushed by state police?

People are just as free in many other industrialised countries, with just as many democratic rights. Freedom is not restricted to the borders of the US. Have you considered that you may not understand how it works in other countries?

As to the rest or your post, I'm not even going to bother addressing it.

I think you just did

 

[downunderwunda]

Well said. But I would like to add that if ambulance services are properly funded, educated & trained then they can, with the appropriate protocol's, reduce the burden on hospitals.

With appropriate resources there is no reason why people cannot be left at home, with protection for the officers, to see a GP later.

Why take a known post octal epileptic to hospital when it is a semi regular occurrence? The most appropriate course of action is to leave them in the care of a responsible person, provided there are no unusual circumstances, with a referral to their own Dr.

Same with a diabetic hypo in a known diabetic, or asthmatic.

Here is one to make you think, gastroenteritis. Contagious, & one of the worst patients to take to any hospital. Provide antiemetics, fluids, stay at home.

Now add up the cost savings to the health system from these patients & redirect it to ambulance training, equipment & education.

Then we might be seen as a true profession, not a bunch of cowboys.

 

[jwk]

What???

I have never had a problem and I have been around a while in some very high volume environments.

Nobody, and I mean NOBODY, has NEVER had a problem with a BVM. You may think you're ventilating EVERY patient adequately, but I can tell you that is simply not in the realm of possibility.

 

[jwk]

Well said. But I would like to add that if ambulance services are properly funded, educated & trained then they can, with the appropriate protocol's, reduce the burden on hospitals.

With appropriate resources there is no reason why people cannot be left at home, with protection for the officers, to see a GP later.

Why take a known post octal epileptic to hospital when it is a semi regular occurrence? The most appropriate course of action is to leave them in the care of a responsible person, provided there are no unusual circumstances, with a referral to their own Dr.

Same with a diabetic hypo in a known diabetic, or asthmatic.

Here is one to make you think, gastroenteritis. Contagious, & one of the worst patients to take to any hospital. Provide antiemetics, fluids, stay at home.

Now add up the cost savings to the health system from these patients & redirect it to ambulance training, equipment & education.

Then we might be seen as a true profession, not a bunch of cowboys.

The Aussies do a lot of things that aren't done in the rest of the world. Penthrane (MOF) inhalers for example. Correct me if I'm wrong, but essentially nobody else uses those.

I'm guessing Australia also doesn't have the medico-legal climate that prevails in the US. Taking your gastroenteritis example - in the US you can't pop them with ondansetron, leave a liter of LR running, and tell them to see their doc tomorrow. There is far too much potential liability. Nor can they start at IV and then hang around for an hour to D/C it. That takes them out of service far too long. That's simply not why they are there.

EMS, at least in the US, is not supposed to be a primary care medical provider. They aren't physicians, PAs or NPs - they aren't trained to that level of differential diagnosis. I'm curious - can you give me a differential diagnosis for nausea, vomiting, and belly pain? Gastroenteritis is the a very tiny tip of the iceberg.

The E is for EMERGENCY - it's not RMS with the R standing for routine.

 

[Brandon O]

The E is for EMERGENCY - it's not RMS with the R standing for routine.

Still in the early stages of development is my idea-baby, a proud institution of Urgent Medical Services -- UMS for short. Staffed with UMTs ("umpties") and UMT-Ps ("ummm, teepees?"), we deal with, ummm, the other stuff.

Coming soon to a region near you. Just dial 119.

 

[docmoods]

My former medical director was 100% in favor of this.

unfortunately, the state isn't as progressive as he was.

Yea ditto...

 

[Scott33]

Suffolk County, NY, are currently looking into trailing IN Narcan for basics.

http://www.suffolkremsco.com/clientuploads/Downloads/BLSNarcanPilotProgramn312.pdf

 

[Av8or007]

Some people need to watch Weingart's "laryngoscope as a murder weapon" lecture. It not only goes into the physiology of intubation, but it also goes into the "art and science" of the BVM and how to use it properly without killing the patient in the process.

 

[wanderingmedic]

Still in the early stages of development is my idea-baby, a proud institution of Urgent Medical Services -- UMS for short. Staffed with UMTs ("umpties") and UMT-Ps ("ummm, teepees?"), we deal with, ummm, the other stuff.

Coming soon to a region near you. Just dial 119.

:rofl:
this made my day. I think that is how I will intro myself to the next call I get from one of our frequent flyers.

 

[StopNgo1000]

Does anyone have any issues with IN narcan ?

the downfall of it?

Of course i see positives...

extending the training to BLS providers, having a different route of administration with it comes to pts that overdose from needles, cutting down the risk of bloodborne pathogens, etc

 

[Wheel]

Does anyone have any issues with IN narcan ?

the downfall of it?

Of course i see positives...

extending the training to BLS providers, having a different route of administration with it comes to pts that overdose from needles, cutting down the risk of bloodborne pathogens, etc

No offense, but did you read the thread? Downsides were discussed in good depth. One is that you run the risk of undereducated providers giving too much and causing acute withdrawal symptoms. Honestly, with the current educational climate this is a risk with ALS providers as well.

 

[StopNgo1000]

My apologies , I read through it fast sorry . Thank you

 

[Wheel]

My apologies , I read through it fast sorry . Thank you

Not a problem, sorry if I was a bit snippy

 

[TheLocalMedic]

I'd rather have a BLS crew put a patient into withdrawls than rely on them to effectively ventilate and apneic overdose. Sorry, but I've seen the volly departments here in action and I can't in good conscience say that they do very well at ventilating people. It's a skill you have to practice to be any good at, and they just don't get to do it often enough to do it well.

 

[Trashtruck]

Or bag them too hard, blow their stomach up, and have them vomit and aspirate before you arrive.

 

[hogdweeb]

service I run with ahs it on board for Basics. I have not gone through the course, but ive heard from the one person I know of who has administered it luckily took the edge off and made the patient "functional" without killing his high.

 

[Bullets]

I'd rather have a BLS crew put a patient into withdrawls than rely on them to effectively ventilate and apneic overdose. Sorry, but I've seen the volly departments here in action and I can't in good conscience say that they do very well at ventilating people. It's a skill you have to practice to be any good at, and they just don't get to do it often enough to do it well.

As if poor ventilation and BVM use is province of volunteers or BLS.

Im no volunteer apologist, if they dont work then they need to be replaced, but BVM use and proper ventilation is a skill no provider gets a ton of practice on and it is a perishable skill. Think how many IV starts youve done in your career, think how many patients youve bagged. I bet you have many more IV starts


There is no need for BLS to carry this. Regardless of the level of education BVM is the better care choice in most cases. As long as the patient is able to maintain a respiratory drive there is little use for Narcan. If a patient is just unconscious and breathing well, then its not an overdose. I see allowing BLS administer IN Narcan as a recipe for lots of providers giving it like Oxygen...."if we have it, why not use it"

 

[Carlos Danger]

Hmmm.....EMT's and narcan.....where do I start?

I would not be appropriate for an EMT to be responsible for choosing whether to use diltiazem vs. amiodarone vs. adenosine to treat a symptomatic tachycardia. Or choosing between propofol and ketamine to facilitate a painful procedure.

However, there are some drugs where the indications are clear and the benefit:risk ratio low. Aspirin for chest pain in a patient with a cardiac history. An epi auto-injector for a kid with a known peanut allergy who is blowing up like a balloon and wheezing like Fat Albert climbing stairs in the school cafeteria. Glucagon auto-injector for the unresponsive diabetic and the glucometer reads "LO". IN versed or a valium suppository for someone with a seizure history in status epilepticus. These are all cases where it's usually pretty clear whether the drugs are indicated, where they probably wouldn't do much harm even if they were given inappropriately, and where having them vs. not having them could potentially be the difference between life and death.

And I think narcan for a suspected opioid OD is along these lines, too. Maybe not quite as clear cut as some of those examples, but pretty close.

Narcan is generally a safe and effective drug. Yes, it comes with risks. But an unsecured airway and a full stomach in a patient who has essentially put himself under general anesthesia is pretty risky, too. Especially when the EMT's (or paramedics) on scene may not be as skilled with the BVM as they should be.

There seems to be a lot of anti-narcan rhetoric on the EMS interwebs lately, and I'm not sure where it comes from. I know some of it is bravado ("I-dont-need-no-stinkin-narcan-I-can-intubate", or it's close variation, "narcan is for nurses - paramedics use plastic!"), but I think a lot of it is just overestimation of the potential hazards of narcan combined with an under-appreciation for the dangers of BVM'ing a full-stomach, narcotized, potentially acidotic patient.

 

[milehimedic]

Boston EMS basics have been administering IN Narcan for sometime now. I am not sure what they're protocols are. I also know of a few police departments (Lynn and Quincy MA) that are also carrying prefilled IN Narcan setups. In Boston it's been very useful given the shortage of ALS trucks and proximity of hospitals.

Colorado EMT basics who have taken a state approved IV access class can also administer Narcan through both IN and IV routes. My IV instructor noted that the difference in onset between IN and IV are nearly identical, though he admitted that this was based only personal experience. Our protocol states to start with 0.4mg and then titrate to effect, up to 2mg.

Given that Narcan is packaged in prefilled syringes and prefilled IN setups, so I don't really see much of an issue with it when it comes to the providers making medication errors. So long as providers are receiving adequate education and aren't out trying to ruin people's highs by slamming the doses in, I think it's a fairly good idea. If the Narcan trial fails initially, then it's time to bring in ALS, or as NVRob said, NPA and bag them.

Colorado even goes one step further. If you are a civilian, you can now obtain prescription narcan after a 1-hour class and administer it in the field. Drug policy here is extremely progressive.

http://www.leg.state.co.us/clics/cl...5A469A6087257AEE00570637?Open&file=014_01.pdf

 

[Tigger]

Colorado even goes one step further. If you are a civilian, you can now obtain prescription narcan after a 1-hour class and administer it in the field. Drug policy here is extremely progressive.

http://www.leg.state.co.us/clics/cl...5A469A6087257AEE00570637?Open&file=014_01.pdf

The Massachusetts Department of Public Health has been giving prefilled IN Naloxone for several years to the family and friends of opiate drug users. It's been very successful.