Versed after Narcan for OD patients?

[johnrsemt]

And I miss doing EJ's. conscious EJ's are the easiest, cause you get the patient to help. and it doesn't hurt as much as drilling them.

 

[VentMonkey]

The last narcotic-induced OD I recall popping an EJ in was on one I had thought about doing a dose of IN trial prior to, but then I spotted what appeared to be venous gold staring at me.

Anyhow, yeah I can’t really trump the level of articulation on behalf of @E tank. I just try and treat, and/ or fix what I can.

As far as their personal life-choices? I could care less. Professional marksmanship at its most simplistic.

 

[VinceVega91]

Hard to say where the sense of gratification comes from for a minority of providers in EMS in being judge, jury and executioner to the patient's they have an obligation to treat. Assuming they even have the competency required to preserve or salvage "precious airways and brain cells" that they think they have, not being able to intellectually separate the provision of lifesaving care from ethical/values/human worth biases is troubling to say the least.

Good families that would otherwise "pass muster" with some of our more sanctimonious colleagues (imagine their relief) lose siblings and children to drug and alcohol addiction every day. It isn't something that happens for the gratuitous purposes of inconveniencing ambulance crews.

If recognizing the humanity of patients is too much of a stretch, consider the professional disadvantages of such an attitude. Not being discrete about such opinions not only makes the person expressing them look like an absolute tool, it reflects poorly on everyone that brings patients to the hospital by ambulance.

And people wonder why EMS workers don't get the respect they deserve.

If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.

I have had it happen twice in the last 6 months: GCS of 3 (but breathing well on their own), just as we arrive someone gives Narcan internasally (because they are unresponsive, not because they aren't breathing): now they are awake and pissed and combative; but still screwed up enough that we have to transport. So we restrain them to the cot, and away we go; and sometime during the 2 hour transport they are still combative and causing problems in the back. So yes I have given Versed.
Personally I would rather bag them than wake them up that much, but I have bagged someone for 2 hours, and that isn't fun either

I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.

 

[VentMonkey]

Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up.

Ya know? I too remember being an arrogant 26 year old fool.

Anyhow, are you even old enough to appreciate the character that was Vince Vega?

I guess I find your ironically dogmatic views and judgements somewhat perplexing given your chosen screen name; perhaps do your Pulp Fiction homework.

Good luck to you, hopefully you grow up soon.

 

[StCEMT]

I actually really like the EJ since they tend to trash decent peripheral veins/have massive EJ's waving like a flag in the wind. However, IM + NPA + BVM/NRB has become my new go to lately after a few not so pleasant IV results.

 

[ParamagicFF]

For those of you experiencing "combative" patients after narcan administration, describe what you feel is combative behavior.
I treat A LOT of overdoses (or more often public doses), and at worst I find them to be uncooperative. Even those patients tend to be cooperative after a few minutes of explaining the situation and their options without judgement or hostility.
Are you truly saying these people are attacking you unprovoked? I find that hard to believe.

 

[FiremanMike]

For those of you experiencing "combative" patients after narcan administration, describe what you feel is combative behavior.
I treat A LOT of overdoses (or more often public doses), and at worst I find them to be uncooperative. Even those patients tend to be cooperative after a few minutes of explaining the situation and their options without judgement or hostility.
Are you truly saying these people are attacking you unprovoked? I find that hard to believe.

This is generally what our experience is as well. With that said, we do get the occasional patient who is truly combative and need to be re-sedated. I'm genuinely curious as to the percentage now but our ePCR vendor is tying up my computer so I can't run the stats. I'll try to remember to come back and evaluate the data tomorrow.

 

[Carlos Danger]

Of course I'm joking. And no we don't do double EJs even though we often suggest the idea. It's just basic medical mischief. We treat these patients accordingly by adequately oxygenating their precious airways and brain cells as well as restoring their consciousness so that we can expedite the rehabilitation process for their "disease".

If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.



I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.

Openly advocating for the abuse of vulnerable patients? Ooh so edgy and tough and cool. You’ll go far, brah.

 

[michael150]

If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.



I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.

I’m going to echo what everyone else else has said and hope you get it through your head. We joined this field to make a difference in people’s lives. The fact that you allowed to take care of patients with this mentality terrifies me and honestly bud, I think it’s time you go into a different field.

Moving on.... I asked one of the attending physicians at work what he thought of this. His response? “You’re paramedics. Use the critical thinking skills we all know you have.” Basically, if the patient is totally unresponsive, give a whole 2mg over a course of 2-3 minutes spacing it out. We can basically send people into withdrawal (something we obviously don’t want) if we push too much at one time. Sooner or later though, the question becomes: should we intubate or secure their airway because obviously they aren’t waking up? As much as I think Versed, Valium, Ketamine are all good agents at controlling combative patients; we brought them out of one unresponsiveness, to put them into a different drug-induced one. If combative? Yes, it may be necessary. Honestly though, if we are taking them out of it slowly and reversing all the agents that can potentially cause the alteration of mental status, it shouldn’t be a fight. That’s my thought and he seemed to agree.

 

[medichopeful]

If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.



I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.

Can administrators ban posters who have this attitude?

 

[FiremanMike]

Finally managed to pull my data.

We primarily administer narcan via MAD which is given 2mg at a time (which I believe to be the standard for MAD dosing). We have yet to find a sweet spot on MAD adminsitered narcan for "just breathing, not awake" so our patients generally go from unconscious to completely awake.

I pulled data back to November 2016 and found that only 1 patient required re-sedation with ketamine/versed after receiving narcan, N=165.

 

[DrParasite]

Finally managed to pull my data.

We primarily administer narcan via MAD which is given 2mg at a time (which I believe to be the standard for MAD dosing). We have yet to find a sweet spot on MAD adminsitered narcan for "just breathing, not awake" so our patients generally go from unconscious to completely awake.

I pulled data back to November 2016 and found that only 1 patient required re-sedation with ketamine/versed after receiving narcan, N=165.

I just want to say, you are one of my favorite firefighter posters on these boards. no sarcasm at all, I love your EMS data driven concepts, your pro EMS points of view, if I could meet you and shake your hand, I totally would.

As to what you said, I don't think your standard is entirely accurate; the standard dose is UP TO 2 mg via MAD dosing, because there isn't really a concrete number due to many variables (the patient, what they took, how much they took, etc). Most places say titrate to effect, but if a little is good, a lot is even better.

So if 2 mg will get them up, walking and talking, and 1 mg will get them breathing and not awake, where now we need to carry them down to the truck, and take them to the ER where they will simply give another 2 MG to wake them up I think you see where this is going.... Not that I don't disagree with them, but I do think that keeping them unconscious but breathing, transporting them to the ER, only to have the ER push more narcan to wake them up and get them to sign out AMA makes me question why we don't just cut out the middle man and wake them ourselves.

I can't recall any ODs (from heroin or other) that needed to be chemically restrained; most were initially combative (waking up with 4 people they don't know hovering over them), but after that initial shock and some verbal calming down and explanation, they were fine. Like you said, 1 in 165, that's a 0.6% occurrence, not very common.

 

[FiremanMike]

I just want to say, you are one of my favorite firefighter posters on these boards. no sarcasm at all, I love your EMS data driven concepts, your pro EMS points of view, if I could meet you and shake your hand, I totally would.

Thanks, you're pretty squared away also! I just gave my first conference lecture and it went well, I think I'm going to submit it to EMS World and see what happens, maybe we can meet up then!

As to what you said, I don't think your standard is entirely accurate; the standard dose is UP TO 2 mg via MAD dosing, because there isn't really a concrete number due to many variables (the patient, what they took, how much they took, etc). Most places say titrate to effect, but if a little is good, a lot is even better.

I should have completed my thought by saying "the standard dose in this area". As a matter of fact, the big city police department next door to us issues those 4mg nasal shooters to their officers, so that's where they start..

So if 2 mg will get them up, walking and talking, and 1 mg will get them breathing and not awake, where now we need to carry them down to the truck, and take them to the ER where they will simply give another 2 MG to wake them up I think you see where this is going.... Not that I don't disagree with them, but I do think that keeping them unconscious but breathing, transporting them to the ER, only to have the ER push more narcan to wake them up and get them to sign out AMA makes me question why we don't just cut out the middle man and wake them ourselves.

I'll just be perfectly honest, I've never personally witnessed anyone administer "just enough" to get them breathing. It's always "give them 2".. wait a few minutes.. still not awake or breathing.. "give them another".. rinse and repeat. I'm not saying it's right, I know how it's supposed to go, I'm just saying how it's always gone in this area..

I can't recall any ODs (from heroin or other) that needed to be chemically restrained; most were initially combative (waking up with 4 people they don't know hovering over them), but after that initial shock and some verbal calming down and explanation, they were fine. Like you said, 1 in 165, that's a 0.6% occurrence, not very common.

We get the occasional puker.. we get the occasional jerk-wagon.. but for the most part we just get the fully awake OD patient who's either embarrassed or (more commonly) defiantly refusing that they partook in opiate pleasure prior to our arrival. We insist they go to the hospital, end up with refusals on about 3% of of them, and move on to the next one.

We were actually awarded a federal DOJ grant this year to help address the opiate issues in our area, not sure how it'll pan out..

 

[johnrsemt]

I usually start with approx. 0.4mg Narcan and go from there.

To the poster who was asking what we consider 'combative': I usually consider it to be someone who is throwing himself around on the cot so much that even with 3 sets of seatbelts and soft restraints; the driver feels the truck moving. Last guy popped the catch on the cot, so that the cot was moving around. 5mg Versed IM helped calm him down after a few minutes.

 

[Summit]

Found an image, made a meme

 

[FiremanMike]

Found an image, made a meme

Ketamine blow darts..

 

[johnrsemt]

Had a patient last weekend on a shift at my part time gig that was running into traffic screaming at cars to shoot him: we talked about it on the way back from the hospital "Last time I checked my car wasn't armed, and if it was it doesn't have a finger to pull the trigger".
But the police got the patient down on the ground: when we got there were 5 officers holding him down. We gave him 5 mg Versed IM to start; put 4 point soft restraints on his wrists and ankles; and then the officers lifted him to the cot (all of this on the street while 5 squad cars, and 2 ambulances had a 5 lane highway closed). Secured him with the Seatbelts and 4 point restraints.
He bounced a few times; and was mainly verbally abusive during the 125 mile transport. Kept talking to his father, mother and doctor (full body people sitting somewhere in the back of the ambulance). Talking to his girlfriends head in the back window of the ambulance. None of them where there, but he was having a good conversation with them. Kept him calm. Any time I tried to ask questions it upset him so I let him talk.
Versed never really did anything to him.
He admitted to Meth for 5 days; that was the only consistent drug he admitted to; sometimes he said that he took a lot of other stuff other times he denied anything else. Always said Meth.

Night before (before I worked) they had a drunk (pulled over for DUI and blew a 0.32) that was high with no idea of what. He was fine until they started transporting him (IV didn't even bother him): 10 miles out of town they are yelling for cops on the radio. PD, fire and 2nd ambulance showed up for help. He bit 1 FF on the hand who felt it through extrication gloves; bit a police officer on the leg, ripped his pants and drew blood. He got 15 mg Versed and 10 mg Haldol, and fought the restraints for 105 miles. He was tased 3 times one the side of the freeway, and 4 times on the way to the hospital (officer who was bit rode in with them).
He never admitted anything but alcohol.

We think that we may have a bad batch of Meth out there; But they like to mix up their own cocktails. The only one I got to the hospital recently that I haven't had to sedate; that I was able to keep breathing with 13 doses of 0.4mg Narcan IVP during the transport ended up with Alcohol, Benzo's, Pot, Cocaine, Meth, X, and Opiates in his blood all at levels that the ED was shocked that he wasn't dead.

 

[E tank]

Found an image, made a meme

People in other fields would just write that off as being photo shopped. Can absolutely see that happening. And being forgotten the next day...oh the stories of the "hallway gurney"....notice the open electrical panel adjacent to the gurney...Staff were probably making bets on who buys beer after work if the guy could make it to the hot water pipes in the ceiling...

 

[Phillyrube]

Why are you waking up OD patient with Narcan? I thought it was just to restore their respiratory drive.

Titrate till they're breathing, not until they become awake and combative. No need for versed.

I put them on ETC02 and pulse ox. NPA for the drill, and transport. If their numbers are good, let them sleep.

I retired from the PD in 2014, and did a lot of the background on police narcan. Still working as a 911 and ED medic, I saw a lot of the results. Narcan given for every unconscious patient PD found. Not the way I wrote up the protocols. I started to make the cop who gave the narcan ride to the ED in tha back, to help me deal with whatever violent vomiting patient I had. Other medics started that too, and when I left the system last year the amount of cop narcan had decreased, with no changes in mortality.

I loved hearing the guys, "C'mon sarge, you can handle it"!! Get in the truck!

 

[DrParasite]

unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done? do they need a 1:1 monitor? do they simply sleep it off like the people who enjoy too much alcohol? or do the EDs give narcan?