The Combative Opiate Patient
- Thread starter Elk Oil
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mycrofft
Still crazy but elsewhere
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I think a thread about "movement restriction" is needed.
Some pts could experience (i.e., "die") from positional asphyxiation or secretion aspiration when forced to lie supine. Anecdotal evidence seems to strongly suggest that some types of drug mania cases can succumb if forced into a posture of aquiescence (sandwiched, or bent double and manacled to a floor grating). This sort of violates the "do no harm" deal I think. Related deaths in EMS (and sometimes law enforcement booking areas and holding cells) can be attributed to the drugs or an unforseeable physical problem (arrythmia, asthma/COPD, obesity, airway abnormality) and the iatrogenic nature of the death or disability (due to anoxia, rhabdomyolysis, etc) missed or swept away.
LE has the "prostraint chair". Maybe we need one that holds then pt in a HAINES position? (One-third serious here).
(I apologize for size. Used without permission).
Some pts could experience (i.e., "die") from positional asphyxiation or secretion aspiration when forced to lie supine. Anecdotal evidence seems to strongly suggest that some types of drug mania cases can succumb if forced into a posture of aquiescence (sandwiched, or bent double and manacled to a floor grating). This sort of violates the "do no harm" deal I think. Related deaths in EMS (and sometimes law enforcement booking areas and holding cells) can be attributed to the drugs or an unforseeable physical problem (arrythmia, asthma/COPD, obesity, airway abnormality) and the iatrogenic nature of the death or disability (due to anoxia, rhabdomyolysis, etc) missed or swept away.
LE has the "prostraint chair". Maybe we need one that holds then pt in a HAINES position? (One-third serious here).
(I apologize for size. Used without permission).
mycrofft
Still crazy but elsewhere
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The prostraint chair has little wheels and a trailer hitch....
Sorry, the photo above previewed ok but farted out in real world.
Sorry, the photo above previewed ok but farted out in real world.
Melbourne MICA
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Some pts could experience (i.e., "die") from positional asphyxiation or secretion aspiration when forced to lie supine. Anecdotal evidence seems to strongly suggest that some types of drug mania cases can succumb if forced into a posture of aquiescence (sandwiched, or bent double and manacled to a floor grating). This sort of violates the "do no harm" deal I think. Related deaths in EMS (and sometimes law enforcement booking areas and holding cells) can be attributed to the drugs or an unforseeable physical problem (arrythmia, asthma/COPD, obesity, airway abnormality) and the iatrogenic nature of the death or disability (due to anoxia, rhabdomyolysis, etc) missed or swept away.
LE has the "prostraint chair". Maybe we need one that holds then pt in a HAINES position? (One-third serious here).
(I apologize for size. Used without permission).
Ditto both these comments.
I've never seen a "scoop sandwich" but it sounds postitively medieaval. I'm glad Mr Brown was so frank and Mr Mycrofft so typically on the money.
What the hell are we talking about here? Heroin OD's for gods sake.
What is a Heroin OD? Any heroin user who has used and is still awake and talking or moving around has not O'D. They may go "on the nod" as the users call it, drifting off but still with it and easily roused. Gee thats what opiates do don't they and why the users take the stuff?
When do we get called? When they stop breathing and are unconscious and unrouseable. So what part of managing an unconscious, unrouseable, non-breathing heavily narcotised patient requires the kind of preposterous approaches I'm hearing here?
They take an OP straight down the gullet with no gag do they not - hint hint - this guy will not wake up when you handle him.
Start bagging, get his sats good - in the meantime your partner has organised his IM jab of Narcan - not so much as a flinch - he's limp for gods sake. Get a BP, auscultate, dot him up and keep bagging while the Narcan takes effect.
All this crap about keeping them unconscious - good luck if you think only the pts resps will pick up but not the GCS at the same time. Your reversing all the effects of the opiates not just the resp depression.
We all certainly need to be safe in such situations of course so we keep our wits about us. But strong arm tactics would fire anyone up especially if they feel vulnerable and threatended -like walking up to find themselves locked down in some contraption or having their limbs restrained.
I think some of the comments I've heard here are seriously off the mark.
MM
TransportJockey
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You have more education and training than me, so I hesitate to call you out on medical information... but it IS possible to titrate to RR w/out getting too much increasing of GCS. I've done it several times. Usually with IV narcan not IM/SQ though.
Melbourne MICA
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Od
But why do you need to do that in the first place? Its ridiculous - no offense.
My experience is the GCS improvement nearly always follows the RR but this whole approach seems like a great way to get yourself in the s*#t when the pt wakes up in your rig. After all we can never know the strength or quantity of Heroin the user has taken, nor what other drugs they have used. So you will never know when to expect them waking up.
The biggest safety advantage of waking them up at the scene is you can exit on the fly if the pt arcs up - he is still drugged and slow. If you're in the rig or carrying them out to it - well good luck.
Believe it or not I think you can establish a reputation with local drug communities. If they know the ambos always treat them with respect, don't have the cops around them, don't hang s##t on them, don't manhandle or strongarm them you are engendering a relationship where there is far less likelihood of trouble.
I've done hundreds of Heroin O'D's and still do them - 2 in the last 3 shifts. I've never been hit and the handful of occasions where the pt arced up were almost entirely when we used the old IV Narcan first - keep them unconscious and restrained approach.
Heroin O'D's don't have to go the ED if they respond to treatment. (Those who don't is a different story of course).
After all, unlike other opiates, Heroins only negative effect/side effect is resp and neurological depression. It does not damage organs of tissues, does not accumulate, is not toxic persay and if you' ve largley reversed the main effects then what is clinically wrong with the pt that requires mandatory ED assessment? The docs at most will give more Narcan and discharge the pt -that's it.
MM
But why do you need to do that in the first place? Its ridiculous - no offense.
My experience is the GCS improvement nearly always follows the RR but this whole approach seems like a great way to get yourself in the s*#t when the pt wakes up in your rig. After all we can never know the strength or quantity of Heroin the user has taken, nor what other drugs they have used. So you will never know when to expect them waking up.
The biggest safety advantage of waking them up at the scene is you can exit on the fly if the pt arcs up - he is still drugged and slow. If you're in the rig or carrying them out to it - well good luck.
Believe it or not I think you can establish a reputation with local drug communities. If they know the ambos always treat them with respect, don't have the cops around them, don't hang s##t on them, don't manhandle or strongarm them you are engendering a relationship where there is far less likelihood of trouble.
I've done hundreds of Heroin O'D's and still do them - 2 in the last 3 shifts. I've never been hit and the handful of occasions where the pt arced up were almost entirely when we used the old IV Narcan first - keep them unconscious and restrained approach.
Heroin O'D's don't have to go the ED if they respond to treatment. (Those who don't is a different story of course).
After all, unlike other opiates, Heroins only negative effect/side effect is resp and neurological depression. It does not damage organs of tissues, does not accumulate, is not toxic persay and if you' ve largley reversed the main effects then what is clinically wrong with the pt that requires mandatory ED assessment? The docs at most will give more Narcan and discharge the pt -that's it.
MM
firetender
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I agree wholeheartedly, unless, of course, it's the second time in that hour, the first time having been a violent response and forceful exit out into the streets. (You can fill in the blank with your own scenario.)
A couple of choices here; call the cops and for sure have far less gentle restraint imposed, or wait for the patient to lose consciousness, respond, protect the crew AND the patient by restraint and THEN administer the drug that brings him back. There are probably more, as well.
Brown, you know better than most that there are so many variables in the biz, it doesn't really pay to make blanket statements about fitness to serve. And, no, I didn't take your statement personally, I just get in hackles about summary judgments amongst ourselves. Don't we get that enough from everybody else?
Yeah, it was bad. Never used for H ODs, but for the unmanageable combative pt BITD before droperidol or versed. I'm glad that kind of stuff is long gone.
Jeff
Some interesting points being made here.
* We used to give narcan IV slowly in 0.4mg increments, or 0.8mg IM. We were encouraged to transport all ODs, and discouraged from cancelling, in case the patient had overdosed on something with a longer half-life than narcan.
* Our goal was always to alleviate respiratory depression and avoid advanced airway management in selected opiate overdoses. Waking someone to a GCS 15 and potentially combative was to be avoided, if possibly. Good ventilation / oxygenation prior to narcan was emphasised. If we were uncertain as to polypharmacy, we were told to intubate and transport.
I think this strategy worked well for us, because we had relatively few heroin users in our city. We saw a lot of IV cocaine, crack, methamphetamine, but relatively few opiate ODs. As a result, our ERs weren't overwhelmed by transported opiate ODs. We didn't have a pressure to keep them out of the ERs. We also had community narcan, where local users could get trained to administer a narcan preload. I'm not sure how big of an impact this made, but there were certainly people being woken up without 911 being called (the protocol was to call 911, but I'm sure a lot of people weren't compliant).
I think when you have cities where heroin usage is more prevalent, your chance of having a pure opiate OD is probably greater, and the incentive to treat and release is higher. I wonder if this is also sometimes tied into healthcare economics? It seems that heroin users wouldn't be a particularly billable segment of society.
* We were advised to place the patient in soft restraints before administering narcan, even though we were using small doses. I'm suprised to see such strong reactions against doing this. This wasn't an attempt to be punitive towards the patient, it was just done on the basis that if someone woke up too fast, or remained confused, that they might decide to fight, especially if they thought we were the police.
I've never really considered that practice in the context of waking up diabetics. It seems like there's an assumption that a diabetic is less likely to come up swinging. Based on personal experience with D50W, it seems like these patients wake up slower than someone given a large dose of narcan. I've had more problem with them being aggressive at that point between being hypoglycemic and unconscious. That's when glucagon was a good option, in my mind.
* I think the scoop sandwich was useful as a form of restraint in times when chemical restraint wasn't available. But I also think it was barbaric, and is best relegated to the same box of tricks with supine restraint. IV (or IM) benzodiazepines are safer for the patient, more legally defensible, and less likely to result in injury. They also solve the problem of how the patient comes off the stretcher once we're at the hospital.
All the best.
* We used to give narcan IV slowly in 0.4mg increments, or 0.8mg IM. We were encouraged to transport all ODs, and discouraged from cancelling, in case the patient had overdosed on something with a longer half-life than narcan.
* Our goal was always to alleviate respiratory depression and avoid advanced airway management in selected opiate overdoses. Waking someone to a GCS 15 and potentially combative was to be avoided, if possibly. Good ventilation / oxygenation prior to narcan was emphasised. If we were uncertain as to polypharmacy, we were told to intubate and transport.
I think this strategy worked well for us, because we had relatively few heroin users in our city. We saw a lot of IV cocaine, crack, methamphetamine, but relatively few opiate ODs. As a result, our ERs weren't overwhelmed by transported opiate ODs. We didn't have a pressure to keep them out of the ERs. We also had community narcan, where local users could get trained to administer a narcan preload. I'm not sure how big of an impact this made, but there were certainly people being woken up without 911 being called (the protocol was to call 911, but I'm sure a lot of people weren't compliant).
I think when you have cities where heroin usage is more prevalent, your chance of having a pure opiate OD is probably greater, and the incentive to treat and release is higher. I wonder if this is also sometimes tied into healthcare economics? It seems that heroin users wouldn't be a particularly billable segment of society.
* We were advised to place the patient in soft restraints before administering narcan, even though we were using small doses. I'm suprised to see such strong reactions against doing this. This wasn't an attempt to be punitive towards the patient, it was just done on the basis that if someone woke up too fast, or remained confused, that they might decide to fight, especially if they thought we were the police.
I've never really considered that practice in the context of waking up diabetics. It seems like there's an assumption that a diabetic is less likely to come up swinging. Based on personal experience with D50W, it seems like these patients wake up slower than someone given a large dose of narcan. I've had more problem with them being aggressive at that point between being hypoglycemic and unconscious. That's when glucagon was a good option, in my mind.
* I think the scoop sandwich was useful as a form of restraint in times when chemical restraint wasn't available. But I also think it was barbaric, and is best relegated to the same box of tricks with supine restraint. IV (or IM) benzodiazepines are safer for the patient, more legally defensible, and less likely to result in injury. They also solve the problem of how the patient comes off the stretcher once we're at the hospital.
All the best.