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

- Rogue Medic

Needle Stick Regrets

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?


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.


You just don’t understand my chronic pain!

Nurse K at Crass-Pollination (in her sidebar, read the definition) writes Saturday morning CRAYZEE!!!!!!!!!!!!!! about a response to an old post of hers What do you do when you start to feel like a drug dealer at work?

First, Nurse K works in the ED (Emergency Department).

Let’s think about that. Chronic pain is something that is long term, so it should not generally result in a trip to the ED. Emergencies are the kind of injuries or illnesses that lead to acute pain. There should be a method, for the patient with chronic pain, to deal with break-through pain. The method should not be to go to the ED. The method should not be to procrastinate on refilling a prescription, until the weekend, so that your doctor is not available. This is manipulative and self-destructive.

The problem patients Nurse K describes are patients who are abusing the system. Legitimate chronic pain patients should be just as upset with these patients as Nurse K is.

The abusers of the system only make it more difficult for those with legitimate chronic pain to receive appropriate pain management.

Legitimate chronic pain patients should hate these people who make a mockery of genuine chronic pain. Those who put on an act to receive their pain medications.

How we deal with pain tells a lot about who we are.

I’ve had patients with extremely bad injuries. Injuries so bad that I feel very uncomfortable not giving them something for pain.

When the patient says, “I’ve had worse,” and I doubt that I have; or “I’ll wait until I really need something,” and I’m hoping that will be sometime before the surgeon starts cutting; or “I used to abuse drugs and nothing is worth living like that again;” or is lying in bed with a heart rate of 150, pale and sweaty, but discouraging large enough doses to make a significant dent in the level of pain; with that perspective, we are able to see the range of response to pain.

What is 10/10 pain?

For most people, burns seem to be the worst kind of pain. Imagine a red hot frying pan.

Now, reach out and touch the tip of your finger to the frying pan for half a second. What would happen if this were done for real? You have a burn. It hurts. Few people would repeat that experiment any time soon.

Now, imagine having your hand being held against the red hot frying pan, the entire palm of your hand, it doesn’t matter which one.

Think about that pain for a while.

If you have any kind of imagination, and you do not have a psychological illness that isolates you from this kind of empathy, then this should make you uncomfortable, at least.

The pain scale is not from This Is Spinal Tap. It does not go to 11.

Work on a burn unit. These patients have experienced this kind of pain, but now are experiencing severe chronic pain similar to the acute pain they experienced with the initial burn. This is not the only kind of acute or chronic pain worth treating. That is not what I am stating.

I am trying to give an idea of what debilitating pain is.

Fibromyalgia is a way to give a name to a much lower level of pain. If it has a name and a diagnosis, well then the drug companies can sell you a treatment for it. Pregabalin (Lyrica) an anti-seizure, neuropathic pain medication is approved for treatment of fibromyalgia. Here is an interesting view of the effect of pregabalin.

In a study of recreational users (N=15) of sedative/hypnotic drugs, including
alcohol, LYRICA (450mg, single dose) received subjective ratings of “good drug
effect,” “high” and “liking” to a degree that was similar to diazepam (30mg,
single dose).

Pregabalin does not have any studies that show addiction to it. It is interesting that recreational users of drugs would rate it as similar to benzodiazepines (part of the class of drugs these drug users desired). Pregabalin, the only drug approved for the treatment of fibromyalgia, is not an opioid (a natural or synthetic derivative of the opium poppy, related to morphine). The idea of using opioids to treat fibromyalgia is not one the FDA appears to be endorsing.

I am very liberal with pain medicine (when OLMC allows it) and I do not take pain lightly.

Encouraging people to lie there, and to give in to the pain, is just the wrong approach. The more you give in to the pain, the more pain medicine you need, the more you become dependent on pain medication, the less you are able to take care of yourself, the more you become a victim of your own response to the pain.

You become your own victim – not a victim of the chronic pain.

This is tragic. The epitome of tragedy, Hamlet, said –

there is nothing
either good or bad, but thinking makes it so: to me
it is a prison.

O God, I could be bounded in a nut shell and count
myself a king of infinite space, were it not that I
have bad dreams.

That last line confuses many people, not having the ability to understand Hamlet’s “bad dreams,” but it would never work if he were to say, were it not that I have fibromyalgia.”

Hamlet’s dead father would come to him in his dreams and tell him that he was murdered by Hamlet’s uncle, who is now also Hamlet’s step father and the new King. Very unhappy times for Hamlet and this is just the beginning!

Hamlet may have been the prince of despair, the Shakespearean character most likely to whine, but fibromyalgia would never have worked for him.

Maybe it was King Lear with his prove to me that you love me, or Othello with his willingness to let Iago convince him that his wife was fooling around, but Shakespeare knew how to write tragedy. All of these responses to adversity prove to be tragic. And fatal. And whiny.

Was Nurse K being inappropriate?

Not at all. Chronic pain patients would be better off listening to her, than those who say just lie there and suffer, but do it dramatically.


Methadonian – a term coined by GuitarGirlRN?

Well, at least he’s creative!


What a lot of commotion over this term. I never encountered it before in my sheltered life, but I like it.

Is it disrespectful?

It suggests that the methadone is in control of the person. And that’s bad.

We must do everything to empower those battling addiction to free themselves from their opiate dependence.

It isn’t the recovering addict’s fault – the addict is powerless. 12 step 101, first day of class.

So, it seems to me that those claiming offense are not stating that the term is inaccurate, just that it is not respectful enough of the addict’s predicament.

GuitarGirlRN (GG) describes the patient (in the original post and comments) as sleeping soundly and requiring naloxone to be awoken. This sounds like someone who has taken an opiate dose that is a little bit above what he normally takes. Addicts develop tolerance. Tolerance means that more is needed to produce the same effect as the original dose. For addicts (including habitual users of methadone) this can mean a dose that would kill a non-addict.

This seems to be the primary reason for 911 calls for heroin overdose,or whatever opiate of the day was consumed at a greater than therapeutic dose). TRA (The Recovering Addict), this one entering the relapse stage of recovery, has not had any heroin for a while. In the spirit of Oscar Wilde, TRA decides that “the only way to get rid of a temptation is to yield to it.” Our TRA is only an amateur pharmacologist and is dealing with a less than pharmacy grade supplier. TRA self-prescribes a dose that is consistent with his daily dose when tolerant. This tolerance no longer exists.

TRA does not have a syringe of naloxone handy when his breathing slows to a dangerous level and/or stops. TRA is accompanied by someone who would be able to inject naloxone into TRA‘s calcified veins, but without any naloxone the only ethical recourse for the fellow more than recreational drug user is to call 911. Tolerance changes the response of the addict so much that it can mean the difference between breathing (something that appears to be essential for life) and not breathing.

For a methadone tolerant individual to get to the point of requiring naloxone to wake up requires significantly more than his normal daily dose, probably several times the dose he needs to get to his therapeutic level. This might occur if he were to consume several days worth of methadone, but this is only speculation and not meant to suggest that anyone in the methadone-dependent stage of recovery would do this.

As was mentioned in several comments – methadone does not get you high.

Good to know. Tell the Methadonian. He appears to have consumed all of his methadone in an attempt to get high. Maybe he consumed heroin, or fentanyl, or some concoction of a little from column A and a little from column B. He is presenting as one who has overdosed on an opioid. He was assessed by GG, treated for this assessment with naloxone, and he improved to the point where comorbidities could be ruled out, then he was discharged.

Prior to leaving he was observed engaging in criminal activity. Stealing hospital supplies that might be needed in that room for the treatment of a true emergency patient. If the resuscitation bag is not present, you hope that the emergency patient is not so hypoxic that the emergency patient actually needs ventilation right away. After all, that is not what an emergency department is really for. The ED exists to cater to those who think only of themselves, but deserve respect while engaging in their monomanias.

GG could have called the police, there might have already been an officer in the ED dealing with one of the methadonian’s ethical brethren.

Can methadone get you high?

I do not have any direct experience consuming methadone, but my experience with people telling me that a drug cannot do A, or only does B, is that they do not know what they are talking about. That individual might be accurate in stating that taking methadone – at the doses that they are accustomed to using – never made them high. Generalizing from that to eliminate the possibility of anyone getting high is a mistake.

Some people like their intercourse with whips and chains, others find this ruins the mood. For one to insist that the other could not possibly derive enjoyment from their particular style would be wrong. Just as it is wrong to assert that one cannot get high from methadone. If methadone does not get the person high, then the apparently common practice of adding a benzodiazepine seems to help create a high.

Perhaps TRA had mixed a benzodiazepine, an opioid, and whatever adulterants might be mixed in. The result was apparently not what TRA was looking for.

Was there anything inappropriate about GG’s post?

Only some of the comments accusing GG of less than exemplary treatment of a patient. A patient treating GG far worse than he had any right to treat anyone. A patient who should not be encouraged to frequent the ED to stock up on methadone.

Sorry for the harsh tone, but GG did not deserve any of the abuse directed toward her. Nurses receive more than enough abuse on a daily basis and a little editorializing about the rough day is a healthy thing.

Updated formatting and links 10-27-10 – 22:40