First, I couldn’t resist – AD, check out her veins!
Well, Gertrude at Ridin’ the Bus has been writing about her fun with the recreational drug community. She even received a standing ovation from them. She mentions that she is also part of this vast Normal Sinus Rhythm blog conspiracy. Shhh. Don’t tell.
I still like the naloxone scene from Bringing Out the Dead.
Too Old To Work, Too Young To Retire has been trying to get Gertrude to give naloxone as an IM (IntraMuscular) injection, instead of IV (IntraVenous). One of the problems with an IV is that there is more blood on the needle. IM doesn’t completely avoid contamination with blood, but unless you stick the needle through a vein or artery, you are going to have significantly less blood/serum contamination. IM sites are supposed to minimize the chance of hitting a blood vessel, not eliminate the possibility. Another route of administration is IN (IntraNasal). A MAD (Mucosal Atomizer Device) is used to mist the medication so that it is more easily absorbed.
More blood = More risk.
Gertrude writes, “My dear you are right. I should have given it IM. I would have too if I didn’t think I would get yelled at by the doc on duty.” I’m not the dear she is referring to. On the other hand, the accentuation is all mine. đ
Why would someone with a ton of education, who is supposed to have the patient’s best interest and the EMS crew’s best interest in mind make such a bad decision?
Maybe the doctor’s motto is, “It’s not my risk. Deal with it.”
Doc on duty – Wake Up!
Everyone seems to live to serve the almighty protocol.
The protocol can be your friend, when it is well written. Most of all, the protocol is supposed to be the patient’s friend. Somebody needs to change this protocol. This is not easy to do in most places. It is not fast, but it can be done. One way is to go to the protocol committee and sit in on meetings, if it is permitted. Talk to the doctors who are most open minded about good patient care. Present them with research supporting the change you are attempting to bring about. Pay attention to the response. Learn from it. Come back with more research and a possibly modified plan. Doctors tend not to respond to the, “In such and such place, they are doing this,” approach.
Maybe you present your position by making it personal for them, for the doctors who write the protocols.
Think about how you would react to being stuck by a dirty needle.
How would that change the way you view this patient, this patient who may now have some of his blood in your veins?
Sharing!
What if this patient does not want to get an HIV test, so that you can feel better?
If the patient does get an HIV test, does it mean much?
Well, the patient is confident that the test will be negative, so that is a good thing. Right?
Not really. People carrying illegal substances frequently agree to searches by the police, knowing that the illegal items they are carrying are easy to find. People are stupid. Stupidity is also one of the risk factors for HIV and hepatitis.
Do not relax and think that you are safe from HIV, because in this group it was not common. Do worry about the extremely high rates of hepatitis.
Hepatitis is much easier to contract than HIV, so what about the Hepatitis B vaccine? It doesn’t do a thing for any of the other types of hepatitis. Hepatitis C is the biggest concern, but there are variations of hepatitis going out to almost half of the alphabet, now.
Back to HIV, if the test comes back negative, you know that months ago they were not infected. Does that help?
You need to go for follow up testing to see if you convert to HIV+.
How does this affect the way you interact with your spouse, children, friends, coworkers, even strangers on the street?
What if you get a false positive test result?
Do you take the prophylactic treatments? What is the risk of seroconversion?
For anyone too young to remember the appearance of AIDS patients before protease inhibitor cocktails, this should give you an idea. These people were photographed at the liberation of Buchenwald. Another condition that tends to resemble this is untreated diabetes. Before insulin was refined to the point where it could be regularly used in humans, this appearance was not uncommon for diabetics as they would waste away and die.
Think about the way that you deal with sharps, now.
Could it be better?
Remember the Big Bad Person with the Basically Boring Presentation? So boring that often the person presenting it is obviously bored? Well, BBP is supposed to be BloodBorne Pathogens. It is not supposed to lull you into a trance-like state or make you as neurotic as Howard Hughes. Here is the CDC site. They provide links to other sites, such as NIOSH (National Institute of Occupational Safety and Health) and their Preventing Needlestick Injuries in Health Care Settings information.
Have you been vaccinated for Hepatitis B?
What do you do with a needle when you are securing an IV? Do you drop it on the floor? Do you stick it in the seat cushion? Do you pass it to your partner? Do you have a sharps container (portable is good, as long as it does not spill) close enough that you can put the needle in without interfering with securing the IV?
It is the responsibility of the person starting the IV to dispose of the needle properly and not expose their partner to a needle stick injury. Clean up after yourself. It is not your partner’s job to clean up after you. If a medic is careless with IVs and endangers others, somebody needs to arrange for that medic to have some behavior modification therapy.
Do we use needles too carelessly?
Do we start too many IVs, heplocks, saline locks, . . . ?
Are our protocols written to protect the patients and protect us?
If not, maybe we should change the way that the protocols are written.
If that doesn’t work, let’s put our creativity to work.
“Of course I started an IV, but it became dislodged when the patient came around. Just look at his veins. He’s been stuck.” Only this would not work for Gertrude’s heroin snorting charmer.
Not that I’m advocating disobeying protocols, that would be wrong. How the protocol is interpreted is a whole different area to explore.
Here are some of the ways that naloxone may be administered. IV, IM, IN, IntraLingual (into the tongue), SubMental (about half way between the tip of the jaw and the thyroid cartilage, through the skin to the tongue for a patient who has trismus), EndoTracheal, Nebulized, and that is not all.Some of these have little use for EMS. For example, if the patient is breathing well enough to use a nebulizer, how much benefit will they receive from nebulized naloxone?
Do your protocols give you options?
If not, why not?
Protect yourself. Come home healthy, unpunctured, and sane.
.
We’ve got the MAD, and I love it. Versed? Up the Nose. Narcan? Up the Nose. Brown Gravy? Up the Nose.I mean, that thing does it all. It should be on a late night infomercial.-MM
Come home healthy, unpunctured, and sane.Oh well,…2 out of 3 ain’t bad. ;)We just got MADs and I love ’em, too!Rogue,…our mutual friend “Ben” @ TLH just gave a lecture on sedating emotionally-disturbed persons using the MAD for Versed, then giving a more potent BZD IM/IV afterwards.
Medicmarch,Mad about the MAD? :-)Brown gravy?Now, you know that taking that hospital food to the patient is a violation of all sorts of rules. What if a medic were to consume some? What kind of measures do you have in place to prevent brown gravy diversion? Maybe it was brown gravy that you slipped on. Rebel without a ladle?
TrekMedic251,”sedating emotionally-disturbed persons using the MAD for Versed, then giving a more potent BZD IM/IV afterwards.”Interesting. It seems counterintuitive to try to spray something into the nose of a person who is combative. Their respiratory rate and amount of air flow should be significantly elevated and would probably interfere with absorption. If you are going to get close enough for MADness, why not just IM the patient and wait a bit?One reason is the inadequate doses we are allowed, but we could switch to B52s. Diphenhydramine, haloperidol, and lorazepam (or midazolam). If only the doctors in the hospital had some experience with this mixture, so they could understand that it works.Oh, no. They might have extrapyramidal symptoms from the haloperidol. If only we had a drug like benztropine (Cogentin) or diphenhydramine (Benadryl) to give them. :-)Or, the concerns of the adverse effects from high doses and IV doses of haloperidol coming from our frinds at the FDA. Droperidol deja vu? Gosh, we’re not giving it IV and we can write the protocol to limit repeat doses to benzodiazepine only.Not that I have an opinion on the matter. I love trying to talk down dangerous psychotics. And I have far too much experience at that, due to inadequate protocols. Yes, that can be read a couple of ways.I’ll have to ask him about this, but it does not sound practical to me.
I just about peed my scrubs laughing the day my ER doc pal ordered 2mg IM of Haldol for the large 27 year old male who punched out the windows in his parents car during his first psychotic break…yeah, he was bleeding everywhere and bucking like a bronco. That needle just makes the situation worse. It’s frustrating because we are the ones that then have to talk the guy down, try and convince him to take ANOTHER needle when the first doesn’t do the trick, and again we are putting ourselves in the line of fire. In my psyche nurse days I saw time and time again the drug induced psychosis patients who were undermedicated in ER’s come up to us, violent and dangerous. I don’t think we ought to snow the world but I do think that sometimes aggressive management of these patients is the safest thing for them and us. Besides, if I ever have to be restrained, PLEASE do it chemically, not physically! ;)Oh, and the brown gravy…can we give that IV?
ABB,Sometimes I think we should snow the world, maybe just put some Xanax in the drinking water. 2 mg haloperidol for a large guy punching out car windows?Car windows are not so easy to damage with your “bear” hands. The windshield is easier to break, but breaking the side windows indicates the potential for this guy to do a lot of damage.Even a tiny woman can be very destructive when “the silicon switch inside her head gets switched to overload.” Not that you don’t know that. :-)That might be a dose that is effective in modifying the behavior of an undereducated, inexperienced ED doctor, no matter how many years he has been an attending or what glorious medical school he attended, but for the patient the dose is clearly low, just an externalization of the doctor’s delusions.As far as the brown gravy is concerned, I am waiting for a convincing study of its effects. I would not recommend it IV, even if a cranberry sauce chaser is used, but that’s just me.
Yes, xanax in the water and and a lorazepam mist near the triage desk… đ
Rogue,….if you can’t get an IV/IM access because the EDP is struggling, do you want to risk an accidental needle stick? Getting something in them via MAD (while being held down by an appropriate number of LEOs) will give you some wedge time before you try something more potent. As I said, talk to Ben about it.
If you can control the patient enough to direct a needleless syringe into the nose and spray the midazolam appropriately into the nares, then the safe IM administration should not be a problem. IM should provide for more consistent absorption and you can use the full cocktail, rather than an inadequate dose of midazolam by the wrong route, call command again and again for more midazolam orders, and not have much of an effect. The patient is breathing heavily, so the drug is not likely to stay in the nose long enough to be absorbed.If we use the right drugs first, rather than baby steps, that will be safer for everyone. Titration is important, but not when you are fighting with a patient.The faster the better, unless the EMS providers cannot manage a BLS airway, not that this method is likely to reach respiratory depression levels.I’ll hunt him down when I am up there again. đ