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Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

‘Narcan by Everyone’ Does Not Seem to be Such a Good Idea

Thu, 22 Dec 2016 22:45:48 -0500 by
 
Now that we have almost everyone giving naloxone (Narcan) to suspected heroin overdose patients, the fatality rate must have dropped. The panacea must have worked. My criticism of the Narcan by Everyone programs must have made me a laughing stock.[1],[2],[3],[4]

No.

Does that mean that I am a prophet and that you should worship me?

No.

Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H.L. Mencken.

I have been pointing out that the plans assumed that there would not be any unintended consequences. I explained what some of the unintended consequences would be. Many people used logical fallacies to justify ignoring the likelihood of unintended consequences. The reasonable thing to do would have been to study the implementation, so that problems would be noticed quickly.

Misdiagnosis – giving naloxone to people who have a change in level of consciousness that is not due to an opioid (heroin, fentanyl, carfentanyl, . . . ) overdose.
 

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.[5]

Bold highlighting is mine.

 

Failure to ventilate – not providing ventilations to a patient who is not breathing. These patients are often hypoxic (don’t have enough oxygen to maintain life) and hypercarbic (have too much carbon dioxide to maintain life). If the patient is alive, ventilation should keep the patient alive, even if naloxone is not given or if the naloxone is not effective. If the patient is dead, giving naloxone will not improve the outcome.[6]

But . . . But . . . But . . . Narcan is the miracle drug!
 


Image credit.
 

In Akron, a small Ohio city, medical examiner Dr. Lisa Kohler has seen over 50 people die of carfentanil since July. Police Lieutenant Rick Edwards says his officers are “giving four to eight doses of [naloxone] just to get a response.”[7]

 

“Every day our paramedics start CPR on someone surrounded by empty naloxone vials… people give the naloxone and walk away,” she (Ambulance Paramedics of BC president Bronwyn Barter) said in an interview.[7]

 

Where should we start?
 

All patients considered to have opioid intoxication should have a stable airway and adequate ventilation established before the administration of naloxone.[8]

 

We keep making excuses for solutions that are neat, plausible, and wrong. Why don’t we start acting like responsible medical professionals and do what is best for our patients?
 

Thank you to Gary Thompson of Agnotology for linking to this for me.

Go read Response: ‘What happens when drugs become too powerful for overdose kits’

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Footnotes:

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[1] The Myth that Narcan Reverses Cardiac Arrest
Wed, 12 Dec 2012 20:45:29
Rogue Medic
Article

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[2] Should Basic EMTs Give Naloxone (Narcan)?
Fri, 27 Dec 2013 14:00:22
Rogue Medic
Article

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[3] Is ‘Narcan by Everyone’ a Good Idea?
Tue, 03 Jun 2014 23:00:38
Rogue Medic
Article

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[4] Is First Responder Narcan the Same as First Responder AED?
Wed, 18 Jun 2014 17:15:43
Rogue Medic
Article

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[5] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed – indexed for MEDLINE]

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[6] The Kitchen Sink Approach to Cardiac Arrest
Mon, 16 Feb 2015 16:00:53
Rogue Medic
Article

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[7] What Happens When Drugs Become Too Powerful for Overdose Kits?
Dr. Blair Bigham
Oct 4 2016, 12:11pm
Article

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[8] Naloxone for the Reversal of Opioid Adverse Effects
Marcia L. Buck, PharmD, FCCP
Pediatr Pharm. 2002;8(8)
Medscape (free registration required?)
Clinical Uses

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Filed Under: Airway Management, Assessment, Critical Judgment, Fentanyl, Heresy, Heroin, Naloxone, Narcan, Pharmacology, Research, Risk Management

Needle Stick Regrets

Sun, 22 Jun 2008 17:48:00 -0400 by

Photo credit

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. 🙂

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.

Photo credit

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.

Of 585 drug users from northern California tested for these serologic markers, 72% were reactive for the antibody to HCV, 71% for the antibody to hepatitis B core antigen, 12% for HTLV-I/II antibodies, and 1% for the HIV-1 antibody.

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.

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By Rogue Medic
Filed Under: Addict, Critical Judgment, Heresy, Heroin, Naloxone, NSR Blog

The Joy of Naloxone (Narcan)

Tue, 18 Mar 2008 21:56:00 -0400 by
Naloxone is an opioid antagonist – it reverses the effects of drugs that are derived from opium – heroin; morphine; fentanyl; the hydrocodone in Vicodin, but does nothing for the acetaminophen (Tylenol); . . . .

We are called for a possible HOD (Heroin OD), we arrive and find a Deborah Peel with pin point pupils, scarred veins with some evidence of recent injections, respirations are less than ten; skin is pale, cool, and dry, . . . .

RM – “How are you doing?”

DP – does not respond.

RM – after applying some painful stimulus, “How are you doing?”

DP – imitates Fred Flintstone cursing, but with worse breath.

RM – might as well start with an easy one “What’s your name?”

DP – “Deborah Peel.”

RM – “It is an honor. Where are you?”

DP – “In my office looking down on all my subjects.”

RM – “That must be some good stuff. What day is it?”

DP – “I forget.” First Monday of the month is not a happy time.

And so it goes with no unusual findings.

Protocols insist that suspected HOD patients receive 2.0 mg naloxone IV.

This patient appears to be protecting his airway and breathing adequately, possibly requiring occasional moderate stimulus to keep up his side of the conversation.

Naloxone would not be in the patient’s best interest – tends to bring on withdrawal, pulmonary edema, hypertension, anxiety, and violence.

Violence is not in my best interest, nor is any deterioration of the patient’s condition.

Time to call OLMC (On Line Medical Command) and request permission to not be complicit in the doctor’s violation of his Hippocratic Oath.

Dr. DP – “Hello, this is Deborah Peel Memorial Hospital, Dr. Peel speaking.”

RM – “Hello, this is RM,” and I proceed to give a colorful description of DP to Dr. DP. Then – “I am requesting permission to withhold naloxone, since this patient does not appear to need it.”

Dr. DP – “Follow your protocol. Give the 2 mg naloxone and transport.”

RM – “We’ll see you in five to ten minutes.”

Well, we were already transporting – no reason to delay on scene with this patient (collected all his belongings and off we went).

I need to set up an IV and am not in a rush – think Reverend Jim getting his license. And I manage to complete the IV and blood draw as we are arriving at the ED. Not wanting to disobey orders, I bring the syringe of naloxone in with me and am getting ready to push it when I see Dr. DP. I point out that things did not happen as quickly as the doctor would have liked and confirm that Dr. DP wants 2 mg naloxone given IV, now.

There is a bed and the nurse directs us to put Deborah Peel in that bed.

Dr. DP – “What is it with you? Just follow orders.”

RM – “OK, but as soon as the drug is in, we are out the door. The patient’s information is all here, with the blood samples, and you have a full report.

Now, I have to point out that this is unfair to the nurses, who will end up doing the majority of the work of dealing with Deborah Peel’s possible withdrawal symptoms and possible violence, but it is tempting to get the nurses to leave the room, call Dr. DP over, give the naloxone, leave, and let the naloxone go to work – it is fast – with nobody to assist the doctor.

I believe that people can learn from their mistakes, some just need things spelled out a bit more clearly than others, but I am an optimist. 🙂

So, we really do not leave.

We stick around to assist with this performance art, but we insist that Dr. DP come and play. As EMS providers, we are cross-trained as rodeo clowns, so we are able deal to with the inner psychiatrist that Deborah Peel is sharing – name calling, kicking, spitting, attempted biting, . . . .

Just what the doctor ordered.

But why would a doctor do this?

Why does this happen regularly, even when the Deborah Peel is not in town?

This is bad for patients.

This is bad for EMS.

And, since it is bad patient care, it is probably also bad for the doctor – legally, ethically, medically, . . . .

You do this one time and word tends to get around. Some see the teaching point, some see a reckless and irresponsible manipulation of orders.

So it goes.

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By Rogue Medic
Filed Under: Heresy, Heroin, Naloxone, Narcan, OLMC Requirements, Opioid, Pain Management, What does a yellow light mean?