The Combative Opiate Patient

[MrBrown]

Gosh you MAS blokes are a bit behind the times, we have IN naloxone, 12 lead interpretation, paediatric cannulation and cardioversion at Paramedic level, ketamine, you name it.

What would Frank Archer say?

 

[Melclin]

Probably that most of those issues are budgetary :wacko:

 

[Melbourne MICA]

Bonjourno Mr Brown

Gosh you MAS blokes are a bit behind the times, we have IN naloxone, 12 lead interpretation, paediatric cannulation and cardioversion at Paramedic level, ketamine, you name it.

What would Frank Archer say?

Now don't you go casting as as a bunch of illiterate reactionaries. It may be true is some cases but not yours truly even if i think progress peaked with frozen pizza.

Now Mr Meclin - naughty boy and no offence intended for following - have you finished the ambo course yet? If so I think you are in about your first of second year at most. The problem you get into when discussing past history or subjects where past experiences add flavour to the subject is you actually have to have had past experiences as an ambo.

Now for Mr Browns info - we trialled IN Narcan some years ago - didn't go on with it - too much wastage, cost issues and the IM route has been highly effective and stilll is.

We also have 12lead, Ketamine, cardioversion, paeds cannulation you name it - but not for the roadies - MICA only. The ALS Paramedics have a lot of ALS skills but there's 3500 ambos in Victoria now, >50% are students, >50% are less than 23yrs old and in our zeal to put bums on seats for response times our organisation has been happy to drop the bar a fair bit or liberally interpret what passes as competencies.

Don't get me wrong there are some outstanding graduates of the Uni courses but there's also far too many staff lacking anything that could be called life or work experience -some are in their first full time job, first car etc.

Anyway - IM Narcan route - has had great success - we used to go IV, the MICA oldies would stop roadies from bagging up the OD pts, so they had time to pop the line in and give a dose. So you wound up with hypoxic, cranky, hostile junkies who felt like S#*t and were ready to smack the first head that came into view. There was also a lot of needle stick risk and actual incidents.
Big OH&S issue

No more. IM -everyone can give it, slow onset, plenty of time to bag up the patient and resolve the hypoxia, gentle gentle gentle - now the pts say sorry for wasting our time. It's all very low key, easy does it with no-one put at risk - No of needle stick injuries - virtually zero.

One of the best changes to our guidelines I think we've ever done.

MM

 

[Melclin]

Now Mr Meclin - naughty boy and no offence intended for following - have you finished the ambo course yet? If so I think you are in about your first of second year at most. The problem you get into when discussing past history or subjects where past experiences add flavour to the subject is you actually have to have had past experiences as an ambo.

I completely agree and I'm more than a little confused at this reply. Its very hard to discuss past history without having been there to actually know what happened. But where did I actually claim to know anything about the past? When I said "If I remember correctly...", I meant it in regards to the literature, not any actual experience and in fairness, I specifically stated that my experience with it was limited.

I have strong opinions on academic matters and I'm reasonably well read, but thats it, and thats all I lay claim too.

 

[Melbourne MICA]

I completely agree and I'm more than a little confused at this reply. Its very hard to discuss past history without having been there to actually know what happened. But where did I actually claim to know anything about the past? When I said "If I remember correctly...", I meant it in regards to the literature, not any actual experience and in fairness, I specifically stated that my experience with it was limited.

I have strong opinions on academic matters and I'm reasonably well read, but thats it, and thats all I lay claim too.

And I also said no offence intended and it wasn't. But the decisions that led to our IM Narcan protocol had nothing to do with cost. They were based on OH&S issues. The IN Narcan trial we had here In Melbourne was undertaken from memory about 6 years ago.

There were OH&S issues involved as well - getting rid of sharps in drug situations was rightfully seen as a good goal to strive towards but when the situtation was examined the pts faired no better with IN narcan and the incidence of needlestick was so negligible with IM - the troops were experienced in using it and knew when to jab or not to jab - that with the extra cost and practical issues like measuring out the right amount it was decided to keep the guideline as it was. So IN Narcan was dumped.

But a lot (most) of the discussions here relate to field work. There is always academic content of course but I guess I' m just saying there is a difference between the two. Sometimes its better to just ask questions than provide answers if you are looking to pick up something useful you can apply in the field. There are a lot of "tricks of the trade" in EMS - some good, some not so good. A solely academic perspective often doesn't illuminate the difference

MM

 

[Melclin]

And I also said no offence intended and it wasn't. But the decisions that led to our IM Narcan protocol had nothing to do with cost. They were based on OH&S issues.

....

But a lot (most) of the discussions here relate to field work. There is always academic content of course but I guess I' m just saying there is a difference between the two. Sometimes its better to just ask questions than provide answers if you are looking to pick up something useful you can apply in the field. There are a lot of "tricks of the trade" in EMS - some good, some not so good. An solely academic perspective often doesn't illuminate the difference

MM

I wasn't refering to the IM narcan when I mentioned cost. I was talking more about the 12-lead stuff. Partly in terms of the equipment, but more so in terms of how much it was cost to train everyone up to that standard and then meet the ever present demands for increased pay for increased skill sets. But it was also just a a throw away line in relation to the fact that I knew brown was just kidding.

I know you weren't trying to offend, I guess I'm just a little sensitive of being accused of being one of "those grads" who think they are god's gift to ambulance practice from day one. The hostile climate that those students have left/continue to leave for other grads who happily recognise the value of experience (and how little experience we ourselves have) is, frankly, quite difficult to deal with.

As it happens, I'd appreciate your input on my hyper-G question in stroke if you have the time, given that you're part of our system.

 

[mycrofft]

IMHE (very limited as to succeful Narcan but lotsa drugs and pseudos)

1. MANY abusers are also using other chemicals, at least in USA. They may have pinpoint pupils or not, but if there is respiratory compromise and other signs congruent with CNS depression, we will tend to do some Narcan. The underlying alcohol, methamphetamines, and other trash may become more evident, along with the attendant toxic psychoses.
2. If a person is a combative sort, and especially if you "wake 'em up" to a hostile and confusing environment, they will tend to flail, be it from sleep, diabetic coma, alcoholic stupor, or OD.
3. Amazing how some people with unconsciousness but normal or nearly normal VS will suddenly "flail" but always manage to hit you on the torso, face or neck? Or suddenly "wake up", and grab on, impaling you on their long grimy fingernails where you are not wearing clothing? Yeah, how very coincidental.

 

[usafmedic45]

IM first choice. I have heard that when they've been down long enough, esp in a cold environment you have to give it a while and maybe top it up but it certainly works well.

That's why sublingual injection works so well. It is largely unaffected by peripheral vasoconstrition and the veins of the tongue drain fairly directly into the jugular veins.

 

[Smash]

We also have... Ketamine

Except you don't have ketamine. The flyboys do, you don't

1. MANY abusers are also using other chemicals, at least in USA. They may have pinpoint pupils or not, but if there is respiratory compromise and other signs congruent with CNS depression, we will tend to do some Narcan. The underlying alcohol, methamphetamines, and other trash may become more evident, along with the attendant toxic psychoses.

We are lucky in that most of our heroin overdoses are pure heroin, maybe with a little benzo thrown in. It's unusual to find patients speedballing. That said, if I suspect a polypharmacy overdose, or that the patient has been down for a long time, I tend to go down the "manage airway, ventilate and transport" route rather than cause us all more issues in the field. If it's a straight forward opioid/opiate/narcotic (did I cover them all?) OD then they can wake up and go home.

 

[Iceman26]

For the record when I was referring to IO's being in protocols I wasn't suggesting they be used for Narcan. I was talking just their use in general, there are situations where they're warranted. Strictly for the use of Narcan is not one of them.

 

[STXmedic]

For the record when I was referring to IO's being in protocols I wasn't suggesting they be used for Narcan. I was talking just their use in general, there are situations where they're warranted. Strictly for the use of Narcan is not one of them.

Agreed. IOs can be nice at times... but IO Narcan is ridiculous!!

 

[emtchick171]

Personally, I like narcan for opiate overdose patients. There have been times that my patient's have became irritated, and became combative, also they will vomit sometimes. It all depends on how dependent the patient has become on an opiate, it also has a lot to do with how fast you push the narcan. If you titrate the dose...usually you will have a problem free procedure.

 

[usalsfyre]

Personally, I like narcan for opiate overdose patients. There have been times that my patient's have became irritated, and became combative, also they will vomit sometimes. It all depends on how dependent the patient has become on an opiate, it also has a lot to do with how fast you push the narcan. If you titrate the dose...usually you will have a problem free procedure.

If your frequently encountering these side effects, why do you like the med?

 

[Sam Adams]

From experience, multiple experiences, opiate OD's reversed with narcan can become combative. For those of you naive enough to think otherwise, I pray it doesn't happen when you're not expecting it.

Smash gave some excellent pointers to combat/ prevent the comabativeness.

I'll add, IN administration seems to have to slowest onset and therefore GRADUALLY reverses the OD. The patient isn't stoned one second and awake and vomiting the next (as seen when it's "slammed" by vindictive medics). In addition, I've found that pt's deal better "waking up" where they passed out. They shoot up in a bathroom, wake them up in the bathroom, not in the lighted environment of an ambulance staring up and a stranger, with a piece of plastic in their mouths that's causing them to gag.

 

[emtchick171]

If your frequently encountering these side effects, why do you like the med?

I didn't say I "frequently" experienced them. I said "there have been times". I don't push narcan fast therefore I don't usually experience problems.

 

[nemedic]

I love IN narcan. for basics in MA, as long as your company has the special project waiver (mine does), the protocol allows basics IN 2mg on orders, with a call to the big doc in the sky for another 2mg. more than that and the medics should already be there and have, or be setting up a line. and my method of choice is nice and slow, and generally after we have them packaged.

 

[MrBrown]

Brown doesn't really think we should be waking up overdoses to be honest.

Nana who has chronic pain syndrome and scoffed down a few too many oral morphine tablets by mistake one morning maybe .... coz she can stay at home with Grandpa to look after her and she can see the pain management clinic about that in the am.

 

[Too Old To Work]

I haven't given IV Narcan in probably 12-15 years. IM is much better as it's absorbtion is slower. We also don't give more than 1mg IM as a general rule. The patient wakes up much more gradually, is less likely to vomit, less likely to be at all agitated, and way less likely to develop Pulmonary Edema. The last is pretty rare but it does happen.

IN might be even better, but I haven't used it enough yet to really say.

 

[Aidey]

I have given narcan IM, IN and IV. Route is generally based on patient presentation.

I really have never had someone wake up swinging. The closest was someone who had aspirated and was freaking out because she couldn't breathe. Most of the time we end up going through the "I don't do heroin" skit.

 

[Smash]

Brown doesn't really think we should be waking up overdoses to be honest.

Nana who has chronic pain syndrome and scoffed down a few too many oral morphine tablets by mistake one morning maybe .... coz she can stay at home with Grandpa to look after her and she can see the pain management clinic about that in the am.

There are definite arguments against waking everyone up, however there are equally valid arguments for it. I am lead to understand that in the late 80s and 90s in Sydney and Melbourne there was a veritable epidemic of heroin, with hundreds of patients overdosing every week in each city. The logistics of taking all of them to hospital would have been quite simply overwhelming. It is impossible to imagine how a hospital would cope with 20 ventilated patients a day on top of their normal workload.

Therefore I believe that the practice of waking them up and sending them on their way was reasonable and did not result in problems for the patients or the service. It is this that I have based my practice off.