The Combative Opiate Patient

Gently does it

Our experience here in Melbourne has been to see dangerous confrontations with Heroin OD's virtually disappear. Depending where you work, Heroin Od's are a daily occurence - went to one this week. At their peak when everyone involved in the Afgan war was trying to make money, we could easily do 3 or 4Heroin OD'S each and every shift - thats just one branch and one shift crew. It was everywhere. Far less so now but nonetheless all too regular.

Our guideline was changed years ago from MICA only IV Narcan with road crews watching on to everyone with IM Narcan and more importantly, emphasis on BVM ventilation and managing hypoxia first. Our doses are 1.6-2.0mg IM with MICA able to give a few more 400mcgm IV doses if needed. It rarely is.

And because we ventilate and give modest doses of Narcan slowly there is no imposed withdrawl syndrome and subsequent pallor, nausea, vomiting, tachy - feeling generally like crap and ready to take it out on someone.

Our O'ds wake up slowly and almost always refuse to go to hospital. Why? Because they are fully awake with no hypoxic hangover or withdrawl symptoms. They feel OK and most often are walking around the room apologising to others or just saying: "sh*t - did I really OD?"

We are happy to leave them be provided there is another half responsible person there to keep an eye on them. No recalls for ambulance, no hospital beds taken up, the user out of harms way but not being hassled by anyone.

Its been and remains a highly effective arrangement - and if you are local you start to realise the local users don't ever hassle you because you don't do it to them.

We know most will use again and occasionally there is a death, or hypoxic brain injury event. We always talk to them and to others around them, give some friendly advice and then get out of their faces.

My perception on this from 15 yrs working in the same area is we have earned their respect. Few Melbourne heroin users give ambos crap because of it.

(Now the amphets, GHB and alcohol is another story)

I've said it before but I think the changes to our Heroin OD guidleines are probably one of the best we ever did.

MM
 
Brown completely agrees, and so do Browns ex heroin addict parents.

Heroin virtually disappeared overnight in the early 1990s here when everybody got on free methadone and clonnies. A heroin overdose here is now extremely rare, once in a career event.

Now, pissed young people who have OD on alcohol and GHB so cannot control their own airway and are vomiting on you while their mates who have vomited all over themselves give you lip and threats about treating their mate on the other hand, are unfortunately not once in a career events, more like once an hour between Wednesday midnight and the following Tuesday at 10pm when the students get paid.
 
I just make it a point to take a minute to use soft restraints to the hands and arms prior to giving narcan. also you can give it slowly and stop when you get them breathing and alert again.
 
tmisbell said:
I just make it a point to take a minute to use soft restraints to the hands and arms prior to giving narcan.
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Ummmmmm......noooooooooooooo!!!!! No no no no no! Please tell me you aren't serious!

also you can give it slowly and stop when you get them breathing and alert again.
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THIS is how you are SUPPOSED to use narcan! The point is not to "wake them up." It is to restore respiratory drive. Personally, if I have an opiate based OD, I get a line in and a vial of Naloxone out, but until I get close to losing respiratory drive, I don't give it. When I do give it, I only give just enough to restore the respiratory drive and get them to respond to verbal (maybe loud verbal). Keep them in that drug induced stupor. As long as they are stable and all, it helps keep them calm and makes your job easier.

It is truly appalling, the number of EMS providers who look at the drug as a way to punish, to ruin a drug high. Sorry folks, that is sick. That pt is a human being. Yes they are messed up, but using a drug to willfully torture someone is disgusting, unethical and borderline evil. Reminiscent of some sadist mid-evil (how the heck is that really spelled) tyrant.

Ok, maybe I exaggerate, but my point is none the less valid. Use the drug as it is intended, to HELP, not to torture psychologically.




Sent from a small, handheld electronic device that somehow manages to consume vast amounts of my time. Also know as a smart phone.
 
I can't count how many times I've given narcan. I can tell you that I've never seen a heroin OD become combative or withdrawal (though I love it when they deny drug use). The ones that have potential for withdrawal (at least that I've seen) are the methadone pts or those being treated chronically with narcs. I'm with most here; give enough to breath and call it good. We're not to the point of cutting them loose after waking them up, though.

Jeff
 
MrBrown said:
Oh come on mate you can't be bloody serious that's wrong on so many levels
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I saw my partner get hit right square between the eyes. I also know a nurse that suffered a broken arm...Ensure Scene safety. You can let him loose later on once he wakes up and realizes you are there to help.
 
tmisbell said:
I saw my partner get hit right square between the eyes. I also know a nurse that suffered a broken arm...Ensure Scene safety. You can let him loose later on once he wakes up and realizes you are there to help.
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Why do I get the feeling these were the consequences for poor administration technique...

Do you routinely tie your diabetics down too?
 
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tmisbell said:
I saw my partner get hit right square between the eyes. I also know a nurse that suffered a broken arm...Ensure Scene safety. You can let him loose later on once he wakes up and realizes you are there to help.
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Scene safety can easily be ensured by administering the drug, watching their reaction and getting ready to back off if they start becoming aggressive Tying down patients may only piss them off more.

I've always said it's not my job to risk injury by trying restrain or get physical with patients. That's the job of the police, or an ICP that can sedate chemically. If anyone wants to leave and threatens violence to myself or partner while we are alone i'll gladly open the Ambulance doors and help them GTFO.
 
tmisbell said:
I saw my partner get hit right square between the eyes. I also know a nurse that suffered a broken arm...Ensure Scene safety. You can let him loose later on once he wakes up and realizes you are there to help.
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This is why I don't bother waking them up. No need to tie them down (SERIOUSLY?) and not much more risk to myself or my partner.
My thoughts for opiate OD :
"They breathing enough relatively normal?"
"Yep"
"K, lets keep them that way and go"
 
TransportJockey said:
This is why I don't bother waking them up. No need to tie them down (SERIOUSLY?) and not much more risk to myself or my partner.
My thoughts for opiate OD :
"They breathing enough relatively normal?"
"Yep"
"K, lets keep them that way and go"
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Yep, let the ER wake them up.
 
I wonder where the "all or nothing" mentality has come from. Narcan and D50 are both good examples of medications that should be dosed low but routinely get dosed at the max recomended.

I tend to give narcan IN more often than the other routes so the side effects from IV administration aren't generally a problem. However if I were to suggest around here that we should be giving it IN or IM and avoiding IV people would think I had lost it.
 
Aidey said:
I wonder where the "all or nothing" mentality has come from. Narcan and D50 are both good examples of medications that should be dosed low but routinely get dosed at the max recomended.
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D50 because it's routinely taught as "one amp" after medic school, at least around here. I've talked to medics who honestly don't know how much dextrose is in a prefill.

My theory on naloxene is it was given so often as a "coma cocktail" drug with no effect, combined with the sadistic mentality of "ruining the high" has lead to routinely slamming two mgs.
 
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Aidey said:
I wonder where the "all or nothing" mentality has come from. Narcan and D50 are both good examples of medications that should be dosed low but routinely get dosed at the max recomended.

I tend to give narcan IN more often than the other routes so the side effects from IV administration aren't generally a problem. However if I were to suggest around here that we should be giving it IN or IM and avoiding IV people would think I had lost it.
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W effectivly titrate Glucose 10% on the pt's response. 150ml bolus then 100ml boluses every 5 minutes while the patients BSL is less than 4.0 mmol.

Naloxone however we have a standard dose for all adult patients which is 1.6mg IM given in 2 x 2ml (800mcg) syringes.
 
Linuss said:
I try not to slam Narcan. I push it slowly to return normal respiration / maybe wake them slowly. Groggy patient = a losing patient in a fight.



I've had more trouble with postictal patients....
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The medics I ride with push just enough to get them awake enough to nod their head yes or no.. no serious coherence.
 
Dougy said:
The medics I ride with push just enough to get them awake enough to nod their head yes or no.. no serious coherence.
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That's on the upper end of my dosing too. I try to teach my basics I ride with that when they give it, that's about all the reaction we want to see. I still had a basic a few weeks back I had a nice talking to about since he decided hot shotting the patient right outside the ED doors was a smart thing to do... Last time I let him attend an OD.
 
TransportJockey said:
That's on the upper end of my dosing too. I try to teach my basics I ride with that when they give it, that's about all the reaction we want to see. I still had a basic a few weeks back I had a nice talking to about since he decided hot shotting the patient right outside the ED doors was a smart thing to do... Last time I let him attend an OD.
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That's how people get punched in the face and their arms broken :unsure:...
 
There was this neighborhood...

...where heroin OD was somewhat routine and it must have been good stuff because on our arrival, the pts. were pulseless and apneic. We didn't know better back then, but pushing the full Magilla was the standing order.

We had enough snap-backs into consciousness and running syndrome (sometimes strongarming their way out the door!) that once the resurrected was out of sight, we'd sit down, relax and wait the 20 minutes it usually took for the Narcan to wear off. We'd sit and wait for that inevitable "Man down; unknown origin" call within just a few blocks of us.

At THAT scene, we'd restrain first by an outdated method that I'm sure has been proven deadly by now, before we transported.

(We're talking around 1980 here. The damage has already been done and I have repented since so don't pick on me!)
 
Scoop sandwich, I'll wager...or something along those lines. Yeah, I've asked for forgiveness too.
 
(I had ZERO problems with the Scoop Sandwich and none of my patients were ever harmed by it; I think it may have been the way I used padding!)
 
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