Intranasal Narcan for All

 I was on Park Street last week headed into El Mercado to get some pernil (roast pork), yucca and tostones for lunch when a gentleman came up to me and showed me his overdose kit.  He said he'd gotten it at the local needle exchange program.  He said he had already used it once when one of his buddies ODed and it worked great (though his friend was initially a little pissed at him, but later came to understand when the friend smacked him and said, "But you weren't breathing, bro!".  The kit contained two 2 mg prefilled Narcan syringes and one atomizer.

 

My EMT partner Jerry just stood there shaking his head.  He didn't understand how some dude on Park Street could give Narcan to his overdosed buddy, but as an EMT Jerry couldn't give it.  In Connecticut basic EMTs can give intranasal Narcan, but only if their service is approved for BLS Narcan by their sponsor hospital.  That hasn't happened yet for our service so no Narcan for Jerry.

And I stood there shaking my head because while as a paramedic I can clearly give Narcan, we are having a severe Narcan shortage at work.  Our supply shelves are bare.  I, at that time, had only 4 mgs of Narcan in my bag, and that was only because I was able to get the second 2 mg dose by raiding another car that had a spare Narcan on the shelves.  I had none on my shelves.

I have been working the streets for 20 years and other than a few brief periods when a particularly strong heroin hit the city, causing seasoned addicts to overdose, I have rarely seen as much heroin on the streets as there is today.  Rarely a week goes by that I don't do at least one overdose.

I am all for everyone being able to give Narcan (when appropriate).  I think it is great that the street dude was able to save his friend.  I would like to see the police be able to give Narcan instead of directing traffic around the car with the blue driver passed out at the wheel at the stoplight.  I would like to  see fire be able to give it instead of having to bag the patient until we show up or perhaps to stand around while the unresponsive patient's respirations decline to near zero  (I have seen both excellent airway management by the fire department and less excellent airway management). And I would like my partner Jerry to be able to give Narcan on the days when he works with a BLS partner and instead of giving Narcan has to bag the patient all the way to the hospital because there are no medics available.

But to be able to give it, we have to have it.  Which brings me back to the guy with the overdose kit.  The reason he stopped me in the first place was he was curious how much each vial of narcan was worth.  I told him I thought it was about sixty dollars a syringe.  "Yeah?" he said, "That's what somebody else told me.  That's a lot."

I wondered why he was so curious.  Was he pleased that the state not only was willing to trust him with life-saving medicine, but with valuable life-saving medicine?  Or was he maybe looking to sell it?

I had a vision then of ambulances lined up outside the needle exchange center where another type of exchange took place.  "I'll give you forty bucks for your kit."  "Throw in your roast pork and a pack of smokes and it's a deal."

The Jug

 There is a clear plastic jug -- actually it is an empty water cooler bottle -- that several times a year gets put on the table by the check-in window in operations. A handwritten note is attached asking for donations to help a fellow employee in need. A lot of money has gone into the jug over the years. Few professions know about hard times as much as ours. And we are not immune to them ourselves.

People in EMS don’t make a ton of money. That wasn’t why they went into this work or why they have stayed. Most need overtime or a second job to get by. And when hard times hit, few have the cushion to absorb them. That’s where the jug comes in. It is never enough, but at least it is something. A brother or sister in need. We see the jug and we reach for our pockets. A child with cancer. A bad accident that has laid someone up unable to work and with a long road to recovery. A sudden death. Over the years I have watched my fellow employees put their money in that jug. Maybe a $5, sometimes a crisp $20, others three or four loose crumpled bills and a handful of change, whatever they have on them.

I expect most EMS places have their own versions of the jug. It is Helping others is who were are.

Well, the jug is back up on the table by the window this week. One of our supervisors lost a son unexpectedly. The supervisor and his wife have eight kids. This was their oldest son (26), who leaves behind twin two-year-old daughters. It’s devastating. They are trying to get all the family home from far ranging places to bury him, including one daughter who is out of the country, as well as handle the bills. The money collected in the jug won’t come close to meeting what they need, but it will help. A friend of the family has also set up a gofund account.

You can contribute by going to this link:

http://www.gofundme.com/pjjjzo

I have only known Mark a year or two, but we all like and respect him here. He came up to our division from downstate. He is a 20-year street medic. He put his time in one the road, and that won’t ever come out of him. He deals with you straight. And he likes being on the road more than being in the office. When he shows up on a scene, we know he is there to help. He is one of us.

If you can contribute $5 or $20 or a number representing a few crumpled bills and a handful of change, that would great. Or if the jug is up in your place of work for one of your people this week, do what you always do. It’s why EMS is a family.

The Mentor (or What They Remember)

 I am working with a young man who I have mentored since his first day as a volunteer at my old suburban post. I have tried to teach him the right way to do the job – to be thorough, to be considerate, to be empathetic, to be professional. We have done many calls together over the years, and he has made great strides from his first tentative days. I work with him now occasionally in the city.

I come in to work this morning and am glad to see he is my partner. They post us in a location straddling two towns. We stop at a doughnut shop for breakfast. And then we are dispatched to a cardiac arrest at a nursing home in one of the towns. My partner fires up the lights and sirens. Depending on who your partner is a cardiac arrest call can cause a little bit of anxiety. I have no anxiety this morning. I can depend on my partner. He is the EMT is in the old saying. Paramedics Save Lives, EMTs save paramedics. I am very proud of him. I flatter myself that he will carry on in my fine tradition long after I have left the streets.

We are not three minutes into our response when we get shut down as a closer unit is now available. My partner shuts off the lights, and then turns suddenly into the Dunkin’ Doughnuts just ahead.

“What you didn’t get enough to eat?” I ask.

“No,” he says. “Isn’t that what you taught me?”

“What?”

“Whenever you get canceled from a lights and sirens response, pull into the next doughnut shop you see so people will think you were using lights and sirens just to get doughnuts.”

“I said that?”

“Yeah, you said it makes you laugh so hard you nearly pee yourself every time you do it.”

“You sure that was me?”

“Yes, you said the thought that someone thought you were using lights and sirens to get doughnuts cracked you up. You would innocently say to the person if they followed you into the doughnut shop, “Oh, no sir, we were on our way to a cardiac arrest and we just got canceled. I’m just trying to grab a quick bite to eat before the next call. We would never use lights and sirens to get doughnuts.”

I have to admit it does sound vaguely familiar. I suppose I might have taught him that.

“You said you need humor in this job to keep you sane. You’ve got to have your laughs, you said.”

“Okay, well," I say. "Well done then.”

What the young remember.

The Ideal Medic

I have been a full-time paramedic for over twenty years and a part-time hospital EMS coordinator for over six years. Over the years my ideas of who the best paramedic is have changed markedly. I used to think the best paramedic was the one with the swagger, the one without fear, who never hesitated to act, who never allowed doubt to enter the equation. And while I still admire many aspects of that paramedic archetype, from both my vantage of twenty plus years on the street and the newer position of someone who can actually match up what happens on the street (or at least as described in the prehospital run form) and what happens to the same patient in the hospital, I have learned that many paramedics I thought were never wrong, can actually be wrong quite often, and that some of the paramedics who I thought were rather dull, have actually pleasantly surprised me time and again.

So here is my new ideal medic(s):

A great medic will call a STEMI Alert even if he is not certain the patient is having a STEMI. He will never hesitate to call for backup on a call (he is not afraid of being seen as weak or unsure) if he thinks it might benefit the patient. A great medic doesn't always get the tube, sometimes she doesn't even try. She'll reach for the combi-tube if she thinks it will protect the airway sooner. While he tries to gauge the moment he enters a scene whether the patient is sick or not, he doesn't lock in his impression. She is not afraid of saying she is uncertain. He gives the benefit of the doubt to the patient. She would rather medicate a drug seeker than deny someone in pain. He considers before acting. Sometimes he is afraid, but he won't let his fear keep him from doing what needs to be done. But he always recognizes that sometimes, the best course is the conservative one. She understands the meaning of the phrase, 'It depends' And if he is criticized or if a nurse or a bystander says something offensive to him, he doesn't feel the need to put them in their place. She talks to her patients as people, explains what she is doing, what she thinks might be going on, she guides them through what is happening. Sometimes he just makes small talk. At the hospital, he seeks follow-up -- even and, in particular-- when he thinks he may have been wrong about a patient. She tries to learn from each call. She does her job. He puts the patient first.

So here's to you, my ideal medics out there. You know who you are. People notice. Carry on! 

The Butler Did it

There are any number of different ways to give a verbal handover report at the ED. All sorts of mnemonics. What form you use may depend on what your hospital expects. I try to tell a story. But I don’t tell a story in the same way I would write one. A written story takes you from point A to point Z with all the twists and turns, ending with the Da Dumm! The Butler Did it.

The other day I was listening to a new paramedic tell a triage nurse a great story of a very interesting call. Lots of the above mentioned twists and turns. It started with "We were called for..." It could just as well have started with "It was a dark and stormy night..." The problem was even though it was a great story the triage nurse was getting very impatient, not to mention she was interrupted by other nurses, doctors and her phone during the course of the medic's novella.

My suggestion to the paramedic was when giving an EMS report to a triage nurse, you have to start with the last line. Begin with “The butler did it,” and then you can explain why you think so. If you are uncertain, you can say, "Either the Butler did it or Miss Scarlet did it."

Here are some great opening lines:

Hip fracture. Asthma. Seizure. Epistaxis. Hypoglycemia. ETOH. You can fill in the blanks from there.

The bottom line is the nurse needs the bottom line first.