Streamline

 This is the first I have written since May. I did not mean to stop writing. I had many thoughts, but just never got around to putting them down. Why no posts? A variety of reasons, primarily time. As I get older I find myself less sure of myself and my ideas. I can spout anything, but it takes time to write well and with reason. I want what I write to be considered and thoughtful. That takes the time to sit down and write and rewrite.

I do not have the full energy that I used to have. Now after work or even at work between calls, I no longer take advantage of the time, what little there is. At home I sit on the couch and talk to my family or watch TV. I am big into cooking shows. in the ambulance, I simply try to stretch my legs and relax a little.

I have two jobs as I have written about previously. Sunday, Monday and Tuesday, I work the ambulance in the city from 5:30 to 17:30, although I often don’t get out till 18:30. When I first started working there twenty years ago, three days in the city wore me out so much I usually spent the next day home in bed all day resting. Now, I go to my hospital job. And where years ago, in between calls, we hung out with other crews in parks or at stations, now it seems we are always on the move, if we are not doing a call, we are driving to a post, usually getting a call before we get to the post or are redirected to another post. You can not do a call for two hours, yet still spend those two hours driving in traffic from one post to the next. I am six foot eight. I used to be six nine, but life has beat me down a bit. The front of the ambulances are getting smaller and smaller faster than I am getting shorter. I had a bout of plantar fasciitis a year ago that made my first steps out of the truck excruciating, but the feet are better now. Still, I don’t get out as nimbly as I used to. It is not unusual for us to respond to 10-15 calls in a shift, and from those do 8-10 transports. We get a fair number of cancels or diversions from one call to the next. We carry these pagers called Zip-its now that emit an annoying beep every time we get a priority call (you can't put the beeper on vibrate for priorities), which can be frustrating as we try to respond on the radio to three different dispatchers (company dispatch, city dispatch, CMED dispatch) all while trying to figure out where we are going, and hit the little buttons on the Zip It to get it to shut up. Some times the Zip-Its go off while we are in the triage line at the hospital or while we are giving a report in the trauma room to a doctor. We have to call dispatch and say we can’t respond to the next call because we are still on this one.

Times are hard in health care. Less money, more work. ED staffs are strapped, and so are ambulance companies. No rest for the weary. And the calls, sure there are some challenging ones, but the non-urgent ones continue to dominate. We have gone to a closest car responds rather than a more nuanced approach of maybe sending the BLS car to the intoxicated person, and leaving the medic free for another, possibly more serious call. The calls lately have been typical: 0ld person too tired to get up, young person with a chest cold too uninformed to get medical care anyway but through the 911 system. Some dogs start to look like their owners. I look like my patients sometimes. 56 year old man close to being too tired to take another step who also has a chest cold.

In my twenty years I have gone through phases of burnout, and recovered each time, so I am not worried that the true love for EMS inside me will fade away. I am lucky now that recently I have been paired at least two days a week with an old partner of mine – a man of my age who has a good spirit and sense of humor. It helps when we are sent on a wait and return while BLS units are calling for medics to have someone you enjoy working with, to pass the day with. We have a good time, cracking jokes and getting laughs out of our patients, believing ourselves comedians.

Wednesdays through Fridays and certain Tuesdays (which I take off from the ambulance job to work the hospital job), I work as a clinical coordinator. The hospital is near my house and I have a great boss. I get to work on many interesting projects. Still, the longer I am there, the more projects I get put on. My to do list includes STEMI Door to Balloon Stats and agenda, stroke reports and stroke workbook, trauma data and pain management project, EBOLA talk, patient handover research projects, 12-lead Exams, coming up with a plan to curb linen loss, EMS breakfast preparation, as well as handling day to day QA, followup and fires to be put out.

I go in very early so I can get some quiet time to work before the crews start coming in. My office is in the EMS room, and I enjoy hearing the crews talk about their calls and their thoughts about the system. I try to get home while the sun is still out so I can take my six year old daughter to the park or to the pool. Of all the time I have to spare this is the most precious to me. At night, we read to each other. We just finished reading the Odyssey (kid's version), which I was thrilled she enjoyed. She was fascinated with the idea of the gods living up on Mount Olympus, and messing with the mortals's lives below. She also thinks Oddysseus is very clever. She liked the Trojan Horse and how he outfoxed the Cyclops. She thinks Oddysseus's nemesis Posiden is very mean.

The last thing I have been doing with my time has been swimming. Every night on the way home from the ambulance, I stop at the pool (we have a great indoor aquatics center in our town very near my house). I was on a swim team when I was ten. Other than that I have over the years swum laps at a slow steady pace. I stumbled into a masters swim program last November in place of running (due to the plantar fasciitis) and fell in love with the workouts and the swim coaches pushing me to swim harder. One coach in particular told me I had the natural build of a swimmer and if I worked hard I could become really fast. With encouragement, I worked hard over the winter and into the spring, and managed to qualify for the World Masters Championships in my age group 55-59. I qualified in the 50 meter freestyle by 1 one hundredth of a second and in the 100 meter freestyle by 3 one hundredths of a second. Since the World Masters Championships were held in Montreal this year and Montreal is only a five hour drive from Connecticut, we decided to do a family vacation there.

It was great, although there was pressure on me as the rules of the event were if you did not surpass the qualifying time in your race, you did not get an official time. Fortunately, I managed to make it.  In the 100 meter freestyle I finished in 1:17:45. In needed 1:18:00 to get an official result. I came in 105 of 123 who raced.  Only 108 made the time.  That's me below in American flag cap..  They had swimmers from 97 countries there.

 

In the 50 meter freestyle, I had to get 34:00 to get an official time. I  made the time with 33:59 and also won my heat.  Overall I came in 95 of 125 who raced.  Only 99 made the time.

While in Montreal, I also got to sample some of the local delicacies, poutine (french fries with gravy and cheese curds) smoked meat sandwiches, horse meat, and Montreal bagels, which have sesame seeds on them and are lighter than American bagels. We also ate at several of the gourmet food trucks Montreal is famous for.

This is perhaps a bit of a tangent away from EMS, but the point is, everyone needs to step away. Swimming (and my family) are that for me. All day at work, I think about getting in the pool. I put on my cap and googles, then climb on top of the starting blocks. I take the start position, then spring (or spring at least as well as a stiff old man can) diving into the water, gliding through the clear aqua blue in streamline under the surface. I feel like all the grime of the city is being washed off me, and my soul and heart are being cleansed. An hour later I am home relaxing, laughing with my children, cooking dinner, then sitting down on the couch and resting. I like to be in bed by 9:30, so I am not too tired to do all over again the next day.

It is Saturday morning now, and the kids are eating cereal and watching cartoons. I think if there is a time for me to write weekly, this is it. If I take advantage of the time, I may be able to start posting again regularly.

In a few minutes, I am going to shout, “Come on kids, get your shoes on, we’re going out." We have a lot on the agenda today. Mini-golf, apple-picking, stop in the pet store to think about what we are going to get when Spike, our beta fish, dies (he has lived most of the summer, but is looking tired these days, resting on the gravel more and more rather than flashing all about) soccer in the park, ice cream, swimming at the pool, and then cookout at home. Maybe even a beer for me. I have become found of the Shock Top Belgian White (I limit myself to one. Two interferes with my sleep, three leaves me tired. I only go for 4 or beyond if I am on vacation and can sleep in or better yet, lay on the beach). Hopefully I am in bed by 9:30, my work clothes and boots laid out for my early morning rise.

Breaker of Men

 We find our patient by the elevator doors in a public building. He is on all fours, dry heaving, and shaking. He says he is in terrible pain. Security tells us he is a visitor to this public building. They don't know anything about him other than that he has been screaming that he is in pain. I do my best to assess the patient. He is alert, with warm, dry skin. His pulse is in the 90's. His abdomen is soft. I tell him we are going to get him on the stretcher and examine him further, and depending on a number of things, we hope to be able to help him. He continues to squirm. He is in his forties, wearing, shorts and sneakers and a tee-shirt. He seems oddly out-of-place. I ask him if he has ever felt this pain before. He says yes. I ask him what caused it on those occasions. He says he has gastroenteritis. In the elevator, he tells me he has no allergies. In the ambulance, I take his pressure and find it within normal limits. I am going to give medicine. I take my patients (for the most part) at their word. Yet, my twenty years experience suggest to me that this man falls into the category of drug-seeker.

I have no doubt but that he is in pain, and as I said, I am going to medicate him. I just wonder at the quality of his performance. The manner that he contorts himself and screams that the pain is killing him and that he is burning are both true to real pain and true to performance pain.

He seems almost like a dog who knows he has to perform in a certain way to get his bone. Or a court jester who has to put on a good show to avoid being kicked by larger men. I get the feeling that while there is passion in his performance, there is no joy. He is doing what he does in order to survive.

"What are you giving me?" he says as I slowly push the plunger on the syringe. "I like Morphine."

"Well, too late. It's Fentanyl," I say. I give him a 100 mcgs, and I watch his whole body relax and he slumps back on the stretcher, and closes his eyes. This is truly one of the better responses to Fentanyl I have seen.

I was expecting to give him at least 200, but the 100 does the trick. In the ED, he sleeps curled in fetal position in dreamland.

I have to say, I have rarely regretted giving pain meds to any of my patients. And I have no doubt medicated many a "drug-seeker."

Do I care if I have been played?

I don't. My job is not to be the Judge Wapner of Drug Seeker Court. My job is to treat my patients as compassionately as I can and bring them to the ED where if they are a drug abuser, they can hopefully get more detailed care aimed at breaking their cycle of dependence. And if they are not a drug abuser, then I have not withheld treatment.

I write about this case in particular because of a pain policy I read recently that comes out of LA. Here are two passages I find striking.

1). Pain changes human behavior. People performing torture have long known that the intentional inflection of pain can cause a person to behave in ways that they normally would not behave just to avoid the pain. Pain is very powerful. Chronic pain changes personalities. People who have been happy and kind their entire life before being subjected to chronic pain (such as arthritis or an old injury) have been known to become irritable, angry and unsociable.

2). Addiction is a very real problem and treatment is very complex. One thing is certain, the treatment of drug addiction is not in the paramedic scope of practice and the withholding of narcotics by a paramedic is not going to end an addiction. It is better to give narcotics to 100 addicts than to deny pain management to a single patient who is in real pain.

Watching my patient contort and squirm and cry out for his medicine made me wonder what he was like before pain got a hold of him, before pain broke him, and turned him into what he was there before us. How often has he had to perform? How long as he had to find creative ways to get the medicine to fill that broken space in him where once he was whole?

Read this document:

Los Angeles Prehospital Pain Management Policy

Bravo to its authors! And while maybe they might want to consider letting their medics give narcs on standing orders, their policy has much in it to emulate.

***

I hope to write more about pain in the coming weeks, including about the raging war between the anti-drug overdose group and those who advocate for humane treatment of those in chronic pain.

Whup Kits and Chihuahas

Many of us in EMS love gadgets I remember when I started another EMT sold me a "whup kit," which was a holster that attached to my belt to hold my tools. I didn't get a big one, just a modest sized one. It held a pen light, trauma shears, bandage scissors, tweezers, and a window punch. I stopped wearing the whup kit after a month or so. I only ever used the pen light and the trauma shears on any kind of regular basis.

I also remember back then how much I liked c-spining people. There was a craft to it. We didn't have head blocks then, so we rolled our own towel rolls. You folded a bath blanket into thirds length-wise, then rolled it tightly and taped it with adhesive tape to hold it firm. It was a skill to secure someone to a board. I never did it half-assed, at least not in those early years when we truly thought we were preventing people from paralysis.

There was a pleasure in using equipment, be it a spinal board and towel rolls or a window punch (which I did use once) that made me feel like a craftsman. How I used to enjoy opening my intubation kit, taking out the laryngoscope and clicking in blade after blade to make certain everything was working properly. I even remember briefly for a period entertaining buying my own intubation kit, much like a plumber or carpenter has his own set of tools.

I remember how much I used to like going to EMS Conferences and checking out all the new gizmos, and hoping that some would make their way to my ambulance. And some of the gizmos we have gotten over the years have been great AEDS, pulse oximeters, glucometers, capnography, EZ-IOs, CPAP, 12-leads, power stretchers, stair chairs with tracks, intranasal atomizers. Still many of the conference gizmos disappeared, or just haven't proven their worth.

I remember I came back from one conference l was all fired up about the ResQPOD. I attended an educational session where the presenter made an outstanding case for it. He was an impressive speaker, and did not appear to have any agenda beyond improving patient care. Only later did I learn that all the studies he cited, including some he had co-authored, were also co-authored by the device's inventor. In time, I learned that all the studies that the inventor had authored were positive, while most of the independent studies showed there were issues with the device. I felt a little burned by this because I had beaten the band for the device in presentations of my own, and once I realized and learned to examine the literature for myself, I felt like I had been played for a fool.

One day I learned that a large first responder service in our area was going to be using the ResQPOD. This it turned out was news to the service's sponsor hospital, who put a quash to it. Nevertheless, bizarrely, a member of Parliament over in Great Britain made a speech to that distinguished body about how a city in Connecticut was using this exceptional device, in condemning a British medical director for removing the device from a local service in his district.

ResQPOD Goes to Parliment

The local fire department here, like many, had fallen prey to a vendor's claims without having the ability to thoroughly understand the research. This is a problem many sponsor hospitals in our state have vendors sell the services on their products, and the services buy them, and then the local hospital says, I don't think so.

At one of regional meetings, we used to have vendors come in and demonstrate the latest products. A salesman came in to talk about the ResQPOD. While I have been impressed by many of the vendors, this salesman was not good at his work. He lacked the medical knowledge to answer our committee's questions, falling back on the superlatives in his sales literature. Although it is funny, I remember him at the time saying the ResQPOD was far better for the patient than epinephrine! Perhaps he was a seer. Maybe today, it can be argued, it harms fewer patients in cardiac arrest than epinephrine does.

I remember not long after the disastrous meeting, the salesman forwarded all members of the committee an article from USA Today, about a man who suffered cardiac arrest. The family Chihuahua started barking and alerted family members who quickly started CPR and called 911. The patient received defibrillation and CPR, including the ResQPOD.

Take Heart America

The article said the patient had a full recovery. The salesman's note said:

see attached article that was published in the USA Today the other day. Just another source for validation. SAVE LIVES NOW!!!

Please let me know if we could set up a time to discuss this further

One of the doctors wrote back:

That was a very provocative article. The evidence was compelling. I think we should launch a campaign to have ever household buy a Chihuahua which clearly is a life saving device. I am not sure if it would be entered in to our database as witnessed arrests or not.

More on the ResQPOD in a minute.

The big device that has been sweeping the EMS World in recent years are the CPR machines. The theory behind these contraptions makes a lot of sense. Good CPR saves lives. Why not make a machine that can do perfect CPR? Yet the studies, and there have been quite a few now of fairly high repute that are not showing this theoretical advantage is bearing fruit. It seems the best that can be said is the machines are as good as human CPR so why have people do it when you can rely on a machine?

For excellent commentary on the recent study involving the LUCUS device, see the following posts by Rogue Medic and Brooks Walsh in Mill Hill Avenue Command, who are far better at analyzing these studies than I am.

Failure of LUCAS to Improve Outcomes in LINC Trial

We Had a LUCUS Save!” No, You Didn’t.

In our region, we addressed the machine issue a few years ago by saying services could only use them with their service’s sponsor hospital’s approval, and then only after comprehensive training to ensure there were no delays in applying them. Several hospitals found themselves in the position of being told by their services that they had already paid the $10,000 each or so for the machine, and so at least one hospital that was not going to approve them, gave reluctant approval.

The services all seem to love the machines. Their members boast of amazing pulses during CPR and an increase in ROSC, but we have seen no evidence of improved neurological outcomes. All the saves in the service I most directly oversee have come from witnessed arrests of people aged 40-69, in public, who get bystander CPR, and early defib, and not much if any epi before they come around. We have no saves we can attribute to the machine. And as far as prolonged CPR, we have a case of a man who got nearly 20 minutes of human CPR on scene before the ambulance could arrive and defibrillate him. He survived neurologically intact.

Some say, well, the machines are great for transportation. Responders are less likely to get hurt, You can do CPR while carrying someone down the stairs. All of which may be true and be a worthy use of the device. But, in our region, we now work nearly all cardiac arrests on scene. We have no cases at our hospital of patients whose arrest precipitated a 911 call, being revived in a moving ambulance, and later walking out with full neurological recovery.

We just approved our state going to Cardiocerebral Resuscitation, which emphasis continuous quality chest compressions. Included in that document is a reference to the CPR machines.

Delay application of mechanical device until 5th cycle of CPR unless it can be reliably applied in less than 10 seconds, without delay in compressions.

During the debate, Brooks Walsh spoke up, and started to question the utility of the machines at all. While I agreed with him (as I do on most issues), I spoke against deleting it because the document was a consensus document, and many of the players had already spent a great deal of money on the machines, which they use extensively in their systems, and were unlikely to approve their elimination. I just wanted to get the document done.

My personal belief is that while the machines may save some people, they likely kill as many through the delay in application. When we arrive, these patients in cardiac arrest are on the precipice of no return. They may not have 30 seconds or even 10 more seconds without perfusion to spare. I believe what we do in those first few minutes makes the difference, not the quality of the CPR as we bump down the road 30 minutes later bringing another dead body in to have the time called on it officially.

I would on another day bring the issue of the eliminating the machines back up for discussion, along with getting rid epinephrine in cardiac arrest, unless the literature changes to show clear benefit. I like to pick battles I think I can win, or if not win totally, get to a compromise position I wouldn't have otherwise gotten to without first extending my argument.

The problem with the machines is that they are so expensive and so many services have already shelled out for them, it is hard to just say no. Despite the lack of evidence of benefit, their supporters persist. I was amused to hear that some have even linked the CPR machine with the ResQPOD and saying it is possibly the combination of devices that make the difference. Maybe it is. But I would like for once, to have it proved. I am all for quality research trials for these devices. But the selling and the buying should halt until their worth can be proved.

Perhaps we should add a Chihuahua?

And speaking of research, instead of seeing all the research center on these expensive devices, I'd like to see the research funding go to questions that likely matter more such as does epi hurt or help? But there is not as much money in epi as there is in CPR machines and ResQPODs. 

BLS Narcan

 There was a recent editorial in the Hartford Courant, First Responders Could Help Cut Heroin Deaths, citing the rash of recent heroin deaths and calling for all first responders to be equipped with Narcan in order to stop the rise. Narcan is provided to first responders in some of our neighboring states, and the editorial writer thought this should happen here as well. It is my understanding that there is a strong political push, some of it coming from the substance abuse community, for such a proposal.

Heroin Related Deaths Up Sharply in Connecticut
Many months ago, we debated BLS Narcan at our state EMS medical advisory committee and despite, what I thought was a well put together proposal, the effort was knocked down very soundly. The reason seemed to be responders have ambu-bags, Narcan is often misused, and if the patient is hypo-ventilating a paramedic should be on the way anyway. Additionally, there was some fear of BLS creep, diluting the paramedic arsenal, and thus the need to have paramedics, which could lead to an overall deterioration of care for all patients. All points largely true.

 

As far as Narcan misuse, I can say that my data in reviewing prehospital care as an EMS Clinical Coordinator and anecdotally talking with other paramedics about calls they have done involving narcan, shows that yes, it can be misused by paramedics. (But with education, we have seen the number of misuses drop considerably.) Generally, the misuse stems from two situations.

 

1) Patient who is unresponsive with pinpoint pupils, but breathing fine. (We used to give Narcan in this situation for "coma of unknown etiology" and our guidelines at the time (1990s into mid 2000's) stated there were no contraindications for emergency use) and

 

2) Person who took heroin, who is altered, but breathing fine. The reasoning seems to be, they are altered, they took heroin, which is bad. I am going to give them Narcan and knock the bad heroin out of their system and wake them so they can admit they used heroin so I will know for certain what is going on. (Not good reasoning from health care providers, whose role is to do no harm.)

 

When operating under the old guidelines, I can say, there were times I did harm to patients. I gave multiple doses of Narcan to an unresponsive patient who, while now breathing on his own, still did not wake up, and was soon in pulmonary edema. I gave Narcan to a paraplegic (due to an old gunshot injury) and wiped out his pain meds while doing nothing to resolve his UTI, which was the true cause of his unresponsiveness. I misdiagnosed a stroke (I called off the stroke alert I had given initially) simply because the old woman with pin point pupils woke up after I gave her Narcan. I assumed her sudden lucidness was due to the Narcan and not the lucid interval of her head bleed. And I put more than a few people into withdrawal by giving more Narcan than needed.

 

I know better now, and fortunately our guidelines reflect our learned knowledge, although there are still many out there who continue to  follow the old way. The fault there has to be shared between the medic and the system for not providing better oversight and remediation.

 

Back to today. Here are three recent situations (four calls - two with similar situations) I encountered, and I will test each as to whether or not I believe equipping first responders and or family/friends would prevent a heroin OD death in these cases.

 

Situation 1. Patient in bathroom of McDonald’s not breathing. We arrive to find the Fire Department first responders already there. They have recognized the patient is hypoxic, and are doing a very nice two person seal, ambu=bag rescue breathing. We examine the patient, get their story, give a light dose of Narcan and the patient is now breathing on their own. A similar situation occurred when a BLS unit was sent for the unresponsive overdose. They called for medic backup and when we arrived, they were effectively ventilating the patient with a bag valve mask. Again, we gave Narcan and the patient began breathing on their own.

 

Situation 2: Patient found in car not breathing. We arrive to find a car in middle of road, patient in front seat, blue, with zero respirations, no response to sternal rubs, but still has a faint pulse. Police officer who found patient is directing traffic around the car. Fire Department not yet arrived. We use ambu-bag and IM Narcan injection, get patient into back of ambulance, where he eventually starts breathing on own well enough that we no longer have to bag.

 

Situation 3: Patient unresponsive in apartment. Roommate heard her breathing heavily during night, found her not breathing this morning. BLS unit doing CPR when we arrive. Fortunately we are able to restore pulses with epinephrine, the patient has spontaneous respirations by our arrival at the hospital, and she walks out of the hospital (actually is sent to a treatment center) a week later neurologically intact, but with likely less brain cells than before.

 

In Situation 1,  Narcan by first responders would not have made any difference, other than sparing several minutes of ambu-bag work. The first patient was found alone by the restaurant manager. The second patient was found by family. Had the family had Narcan on hand, there would not have been a 911 call, and the patient presumably would have lived to shoot heroin again another day.

 

In Situation 2, If the police officer had Narcan and used it, it could have been the difference in a similar case. You could argue that if the police officer had an ambu-bag, he could have used that, all while hoping not to get hit by traffic. My experience has been in those towns where police are not the designated first medical responder, they do not carry ambu-bags or assist with respirations by any means.

 

In Situation 3, if the roommate had Narcan, and recognized patient’s unresponsiveness as the result of her heroin use (which is no certainty), she could have possibly prevented the cardiac arrest in the first place if she had administered the Narcan before the patient actually arrested, although she likely would have had to deal with a pissed off roommate, who might have left with back rent unpaid.

 

I am all in favor of Narcan for family and friends of known opiate abusers, and I would also favor law enforcement carrying it, as they may not all be carrying ambu-bags or have the help of knowledge to use them most properly.

 

I have in the past stepped off the fence to the side of Narcan for first responders and BLS despite the potential ill effects of using it incorrectly on stroke patients, non-opiate ODs, and for opiate overdoses who do not need it, and who could thus be put into withdrawal.

 

Having said I am for their using it, I don't buy their arguments that it will save lives that couldn't otherwise be saved.   It will, however, make care easier, and I am for that.

 

If we are going to give Narcan to BLS and first responders, we just have to make certain there is adequate training and oversight to see that it is only used in tight-well defined situations, and not just to use it because a person is unresponsive or used heroin.

 

Just because EMS has misused and may currently misuse a drug doesn't mean they can't be or shouldn't be taught to use it properly.  That is what EMS systems and medical directors are for.  Medical Direction needs to step up to the plate here and take responsibility. Review every use of Narcan. If people are practicing bad medicine, it needs to be pointed out and remediated. Education.

 

I also particularly think that the IN form of narcan lends itself well to non-paramedic use. I have found it to be very mild and with less chance of side-effects than IM or certainly, IV. I found it very interesting in a comment to a recent post of mine a paramedic in Lousiana said they are required to first give the drug IN for just that reason.

 

Bottom Line:  IN Narcan provides the drug in a mild form that is easy to administer, and if used properly by BLS and first responders,  is unlikely to cause harm greater than the benefit it may provide.

 

***
Here is an older post I wrote on the same topic:

IN Narcan for BLS

***

I will keep you all updated as to the outcome of this debate here in Connecticut.

New World Heroin

 There was a recent editorial in the Hartford Courant, First Responders Could Help Cut Heroin Deaths, citing the rash of recent heroin deaths and calling for all first responders to be equipped with Narcan in order to stop the rise. Narcan is provided to first responders in some of our neighboring states, and the editorial writer thought this should happen here as well. It is my understanding that there is a strong political push, some of it coming from the substance abuse community, for such a proposal.

Heroin Related Deaths Up Sharply in Connecticut
Many months ago, we debated BLS Narcan at our state EMS medical advisory committee and despite, what I thought was a well put together proposal, the effort was knocked down very soundly. The reason seemed to be responders have ambu-bags, Narcan is often misused, and if the patient is hypo-ventilating a paramedic should be on the way anyway. Additionally, there was some fear of BLS creep, diluting the paramedic arsenal, and thus the need to have paramedics, which could lead to an overall deterioration of care for all patients. All points largely true.

 

As far as Narcan misuse, I can say that my data in reviewing prehospital care as an EMS Clinical Coordinator and anecdotally talking with other paramedics about calls they have done involving narcan, shows that yes, it can be misused by paramedics. (But with education, we have seen the number of misuses drop considerably.) Generally, the misuse stems from two situations.

 

1) Patient who is unresponsive with pinpoint pupils, but breathing fine. (We used to give Narcan in this situation for "coma of unknown etiology" and our guidelines at the time (1990s into mid 2000's) stated there were no contraindications for emergency use) and

 

2) Person who took heroin, who is altered, but breathing fine. The reasoning seems to be, they are altered, they took heroin, which is bad. I am going to give them Narcan and knock the bad heroin out of their system and wake them so they can admit they used heroin so I will know for certain what is going on. (Not good reasoning from health care providers, whose role is to do no harm.)

 

When operating under the old guidelines, I can say, there were times I did harm to patients. I gave multiple doses of Narcan to an unresponsive patient who, while now breathing on his own, still did not wake up, and was soon in pulmonary edema. I gave Narcan to a paraplegic (due to an old gunshot injury) and wiped out his pain meds while doing nothing to resolve his UTI, which was the true cause of his unresponsiveness. I misdiagnosed a stroke (I called off the stroke alert I had given initially) simply because the old woman with pin point pupils woke up after I gave her Narcan. I assumed her sudden lucidness was due to the Narcan and not the lucid interval of her head bleed. And I put more than a few people into withdrawal by giving more Narcan than needed.

 

I know better now, and fortunately our guidelines reflect our learned knowledge, although there are still many out there who continue to  follow the old way. The fault there has to be shared between the medic and the system for not providing better oversight and remediation.

 

Back to today. Here are three recent situations (four calls - two with similar situations) I encountered, and I will test each as to whether or not I believe equipping first responders and or family/friends would prevent a heroin OD death in these cases.

 

Situation 1. Patient in bathroom of McDonald’s not breathing. We arrive to find the Fire Department first responders already there. They have recognized the patient is hypoxic, and are doing a very nice two person seal, ambu=bag rescue breathing. We examine the patient, get their story, give a light dose of Narcan and the patient is now breathing on their own. A similar situation occurred when a BLS unit was sent for the unresponsive overdose. They called for medic backup and when we arrived, they were effectively ventilating the patient with a bag valve mask. Again, we gave Narcan and the patient began breathing on their own.

 

Situation 2: Patient found in car not breathing. We arrive to find a car in middle of road, patient in front seat, blue, with zero respirations, no response to sternal rubs, but still has a faint pulse. Police officer who found patient is directing traffic around the car. Fire Department not yet arrived. We use ambu-bag and IM Narcan injection, get patient into back of ambulance, where he eventually starts breathing on own well enough that we no longer have to bag.

 

Situation 3: Patient unresponsive in apartment. Roommate heard her breathing heavily during night, found her not breathing this morning. BLS unit doing CPR when we arrive. Fortunately we are able to restore pulses with epinephrine, the patient has spontaneous respirations by our arrival at the hospital, and she walks out of the hospital (actually is sent to a treatment center) a week later neurologically intact, but with likely less brain cells than before.

 

In Situation 1,  Narcan by first responders would not have made any difference, other than sparing several minutes of ambu-bag work. The first patient was found alone by the restaurant manager. The second patient was found by family. Had the family had Narcan on hand, there would not have been a 911 call, and the patient presumably would have lived to shoot heroin again another day.

 

In Situation 2, If the police officer had Narcan and used it, it could have been the difference in a similar case. You could argue that if the police officer had an ambu-bag, he could have used that, all while hoping not to get hit by traffic. My experience has been in those towns where police are not the designated first medical responder, they do not carry ambu-bags or assist with respirations by any means.

 

In Situation 3, if the roommate had Narcan, and recognized patient’s unresponsiveness as the result of her heroin use (which is no certainty), she could have possibly prevented the cardiac arrest in the first place if she had administered the Narcan before the patient actually arrested, although she likely would have had to deal with a pissed off roommate, who might have left with back rent unpaid.

 

I am all in favor of Narcan for family and friends of known opiate abusers, and I would also favor law enforcement carrying it, as they may not all be carrying ambu-bags or have the help of knowledge to use them most properly.

 

I have in the past stepped off the fence to the side of Narcan for first responders and BLS despite the potential ill effects of using it incorrectly on stroke patients, non-opiate ODs, and for opiate overdoses who do not need it, and who could thus be put into withdrawal.

 

Having said I am for their using it, I don't buy their arguments that it will save lives that couldn't otherwise be saved.   It will, however, make care easier, and I am for that.

 

If we are going to give Narcan to BLS and first responders, we just have to make certain there is adequate training and oversight to see that it is only used in tight-well defined situations, and not just to use it because a person is unresponsive or used heroin.

 

Just because EMS has misused and may currently misuse a drug doesn't mean they can't be or shouldn't be taught to use it properly.  That is what EMS systems and medical directors are for.  Medical Direction needs to step up to the plate here and take responsibility. Review every use of Narcan. If people are practicing bad medicine, it needs to be pointed out and remediated. Education.

 

I also particularly think that the IN form of narcan lends itself well to non-paramedic use. I have found it to be very mild and with less chance of side-effects than IM or certainly, IV. I found it very interesting in a comment to a recent post of mine a paramedic in Lousiana said they are required to first give the drug IN for just that reason.

 

Bottom Line:  IN Narcan provides the drug in a mild form that is easy to administer, and if used properly by BLS and first responders,  is unlikely to cause harm greater than the benefit it may provide.

 

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Here is an older post I wrote on the same topic:

IN Narcan for BLS

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I will keep you all updated as to the outcome of this debate here in Connecticut.