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

- Rogue Medic

Naloxone in cardiac arrest with suspected opioid overdoses

ResearchBlogging.org

Peter Canning is doing a countdown of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic. Number 15 is Narrower use of Narcan, which is important and an improvement in patient care. The topic did encourage me to write about this study on naloxone (Narcan) in cardiac arrest from suspected opioid overdose.

Can naloxone improve survival from cardiac arrest?

This is an interesting study that looks at some old charts to try to figure out if naloxone made any difference when it was given to cardiac arrest patients suspected of having an opioid overdose. Here is the interesting part of their hypothesis –

Naloxone has been demonstrated to reduce action potential upstroke in guinea pig, canine, rabbit, and sheep myocardium.8,18,19 The inhibition of action potential upstroke is correlated with the inhibition of fast inward sodium currents. In addition, an effect on repolarizing potassium currents has been shown to suppress re-entrant rhythms by prolonging action potential duration and increasing the refractory period.23 Therefore, naloxone’s antiarrhythmic activity appears to be similar to both class I and III antiarrythmics.23 [1]

Amiodarone also has a shotgun effect on the conduction system, just like the person who decides to change all of the settings on a ventilator without waiting to see what any of the effects might be.

Of course, relying on an antiarrhythmic effect is not likely to improve survival, but it is worth studying.

There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.[2]

The result appears to be just more people dying in the hospital, but ROSC (Return Of Spontaneous Circulation – the short-term change that rarely lasts when obtained with drugs) is hard to ignore.

I have pointed out that the addition of naloxone to the ventilation and epinephrine we are already giving is not likely to add any benefit. With respiratory depression/rerspiratory arrest as the suspected cause of cardiac arrest, these patients are some of the minority who may benefit from ventilation and should be ventilated. When the potentially reversible cause is hypoxia/anoxia, ventilation is a part of the treatment.


Click on images to make them larger.

Not a lot of patients, but New Jersey protocols require medical command permission to give naloxone in cardiac arrest, so there is not a lot of dumping of drugs that “couldn’t hurt” and are possibly coincidentally nearing their expiration date.

Changes in original rhythm noted immediately following naloxone administration, but before additional pharmacologic interventions, were defined as immediate changes. Delayed changes were defined as cardiac rhythm changes occurring after additional medications were administered but within a 10-min interval following initial naloxone dose. The primary outcome measure was change in cardiac activity from baseline based upon EKG rhythm. Secondary outcome measures examined included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.[1]

If the primary endpoint is a change in rhythm, then it appears that the naloxone is being given as an antiarrhythmic, but it is difficult to measure any effect on anything else naloxone might affect.

Naloxone was never the first drug given, but it was occasionally the last prehospital drug given, because of ROSC.

What were the results?

The charts reviewed were from 01/01/2003 to 12/31/2007, so all of the asystole and PEA (Pulseless Electrical Activity) patients had atropine in the protocol. Only one patient started in VF (Ventricular Fibrillation).

Only one patient survived. A 36 year old female, found in asystole. She received epinephrine two times and atropine two times over a 13 minute period. She remained in asystole. Following medical command orders, she received 2 mg naloxone and converted to sinus tachycardia (130 bpm) within 2 min.

She survived to be discharged at 11 days. No information on neurological function is provided. She may have gone to a nursing home or she may be a brain surgeon. We do not know.

1 out of 36 is just 2.8%. Not very good, but these were patients presenting in asystole/PEA, so nothing good is really expected.

At the end of the paper, the authors switch to claiming that this use of naloxone is somehow reversing opioid-induced histamine release. As if we do not successfully treat histamine release much more successfully with epinephrine.[3] Every patient received epinephrine at least one time in doses much larger than would be used for anaphylaxis prior to receiving naloxone. Anaphylaxis is the most extreme example of a histamine release effect.

If there is a positive effect from naloxone, that would be good to know. Unlike most other drugs used in cardiac arrest, naloxone does not appear to produce any significant harm to the heart or brain when used to treat cardiac arrest.

While we definitely do not want to just make this a part of the treatment algorithms without much better evidence, we should find out if there is any benefit. If naloxone has antiarrhythmic properties, is there any reason to limit the research to suspected opioid overdose? This might be difficult to study prospectively, although the other UMDNJ hospitals would seem to be ideal locations to look for suspected opioid overdose patients.

Footnotes:

[1] Naloxone in cardiac arrest with suspected opioid overdoses.
Saybolt MD, Alter SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA.
Resuscitation. 2010 Jan;81(1):42-6. Epub 2009 Nov 13.
PMID: 19913979 [PubMed – indexed for MEDLINE]

[2] Antiarrhythmics
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Free Full Text from Circulation with link to PDF Download

[3] What About IV Epinephrine for Patients Who Are Not Dead
Rogue Medic
Fri, 30 Mar 2012
Article

Saybolt, M., Alter, S., Dos Santos, F., Calello, D., Rynn, K., Nelson, D., & Merlin, M. (2010). Naloxone in cardiac arrest with suspected opioid overdoses Resuscitation, 81 (1), 42-46 DOI: 10.1016/j.resuscitation.2009.09.016

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What About Nebulized Naloxone (Narcan) – Part II


This is continuing from Part I about a recent paper looking at the use of nebulized naloxone (Narcan) to treat possible opioid OD (OverDose).

What are the indications for naloxone?

To diagnose heroin OD?

 

Absolutely not!

 

If we are that bad at assessment, that we need naloxone to identify a heroin OD, then we are not good enough at assessment to be treating patients with any medications.

The protocol-specified nebulization of 2 mg of naloxone with 3 mL of normal saline as empiric treatment for suspected opioid overdose or undifferentiated depressed respirations as long as the patient had some spontaneous respiratory effort, no apnea, and no severe cardiorespiratory compromise (shock, impending respiratory arrest).[1]

In other words, patients who probably will not receive much benefit from naloxone.

Excluded from analysis were cases where nebulized naloxone was given for opioid-triggered asthma and cases with incomplete outcome data.[1]

The omission of the patients (only 3 patients) with incomplete outcome data is legitimate, but not enough data is presented in the paper.

The omission of the asthma patients (21 patients) is interesting. Why not break them out into a different group and analyze with the asthmatics, without the asthmatics, and just the asthmatics? We are trying to find out what works and if it is safe, aren’t we?

Secondary outcomes included need for rescue naloxone (IV or IM), need for assisted ventilation by bag–valve–mask (BVM) assistance or intubation, and adverse antidote events (respiratory arrest, cardiac arrest, death in the field).[1]

The word need is used rather casually. How do they define need?

Why are rescue naloxone, BVM assistance, and intubation not considered adverse antidote events, while respiratory arrest, cardiac arrest, and death are considered adverse antidote events? I do not see the distinction.

I don’t think that naloxone-induced respiratory arrest is going to catch on as a diagnosis. Maybe they are referring to patients who did not receive enough naloxone, due to respirations that are too shallow?

We found that nebulized naloxone is a safe and effective needleless antidote for prehospital treatment of suspected opioid overdose in patients with spontaneous respirations. Eighty percent of the patients treated had some response to treatment, and only 10% of the patients were given a second dose of naloxone. No patient required intubation or BVM-assisted ventilation.[1]

Why were partial responders not given more naloxone?

Why were any of these patients given naloxone?

In our study, no patient signed out against medical advice and all patients were transported to the hospital.11 [1]

22% had complete response to the nebulized naloxone. 5% had complete response to the rescue naloxone.

Nobody refused treatment of transport?

How complete was the response?

Do the police threaten to arrest the patients unless they agree to transport? Why do all of the patients complete the transport?

The literature on intranasal naloxone exemplifies this problem, thus the GCS, respiratory rate (RR), and paramedic impression have been used as outcome measures by others as well.4 – 7 [1]

What about skin color and temperature?

What about pulse oximetry and waveform capnography? These are objective.

Maybe the outcome measures depend on the original indication for naloxone.

Is GCS (Glasgow Coma Score) important?

Not really.

The patient is not going to die of a depressed GCS. Depressed/absent respirations are a different story.

Finally, we did not compare nebulized naloxone with IV naloxone, the recognized “gold standard,” nor were we able to confirm opioid overdose through hospital records.[1]

Gold Standard?

For what?

The goal of treatment is a patient able to protect his own airway and breathing adequately, regardless of whether the patient has ever received any naloxone. Giving naloxone to a patient who meets these criteria is not good medicine.

To be continued in Part III.

Footnotes:

[1] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed – as supplied by publisher]

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What About Nebulized Naloxone (Narcan) – Part I

There is a recent paper looking at the use of nebulized naloxone (Narcan) to treat possible opioid OD (OverDose), or something like that. It is not exactly clear what is being treated. First, we probably want to minimize the use of IV/IM needles when dealing with a population that is not expected to be good at preventing transmission of bloodborne pathogens, even where needle exchange programs decrease that risk.
 


Image credit.
 

Needleless naloxone may be easier when intravenous (IV) access is difficult and may decrease occupational blood-borne exposure in this high-risk population. Several studies have examined intranasal naloxone, but nebulized naloxone as an alternative needleless route has not been examined in the prehospital setting.[1]

It is a good idea to compare the two treatments and to include placebo versions of both. If only one route/treatment is being used, to at least compare that route/treatment with placebo. This is the way that we learn what works, but that is not the way this study was run.

The second reason this makes for a poor outcome measure is that the medics are not “blinded” to the treatment the patient got – they all knew they were giving an active agent.[2]

Without anything to compare the treatment with, we are only determining if the result is acceptable.

What does acceptable mean in this study?

Did the naloxone improve the any patient’s respiratory rate?

Did the naloxone improve the any patient’s pulse oximetry?

Did the naloxone improve the any patient’s heart rate (bradycardia is a common side effect of opioid-induced respiratory depression)?

Or did the naloxone just appear to improve the level of consciousness of some patients?

Why should we be giving naloxone?

The documented indication for nebulized naloxone administration was suspected opioid overdose in 70 patients (66.7%), altered mental status in 34 patients (32.3%), and respiratory depression in one patient (0.9%).[1]

 

Why?

 

Suspected opioid OD (not just any OD and it depends on what else is on board) with respiratory depression.

Without respiratory depression, there is no need for naloxone, unless it is to get the patient to walk to the ambulance. If that is the reason, does the patient really need to be transported to the hospital?

Is that really better than giving the Goldolocks amount of naloxone to allow the patient to safely refuse further treatment? The concern is the respiratory depression/inability to protect the airway.

Aren’t we checking for a gag reflex?

Not me. Where is the benefit in that?

If the patient is not breathing adequately, is there any expectation that giving a nebulized reversal agent will effectively treat the respiratory depression? That is the question that should have been asked. I think that there is a good reason to expect nebulized naloxone to work with significant respiratory depression and that it may be safe and effective, but I think that we definitely need to demonstrate this in a study that documents the changes in vital signs, so that we can identify potential problems early.

To be continued in Part II and Part III.

Footnotes:

[1] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed – as supplied by publisher]

[2] Narcan Nebs – Why? New research doesn’t say..
Sunday, January 22, 2012
Mill Hill Ave Command
Article

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Happy Excited Delirium


What a Trip! is a post over at EMS Outside Agitator. firetender discusses a video of Excited Delirium Syndrome (ExDS). Some people may think that this patient does not have excited delirium, because the patient is so cooperative. That is a mistake.

If EMS had this patient on the monitor, there would be a lot of artifact, but we should expect to see a very elevated heart rate. Probably over 120 beats per minute. The patient is not trying to harm anyone else, but his body is working so hard that he can be hurting himself. He is a danger to himself. If over 8% (one out of every dozen) of these patients die from excited delirium, he will probably not die.

Wait – looking at those numbers is misleading without putting the numbers in context.

The majority of lethal ExDS patients die shortly after a violent struggle. Severe acidosis appears to play a prominent role in lethal ExDS-associated cardiovascular collapse.[1]

We also do not know how much sedation will affect the outcome. We need some sort of studies comparing the outcomes of excited delirium patients who are not sedated with the outcomes of excited delirium patients who are sedated.

While regular exercise is protective and youthful bodies can withstand more punishment, extreme stress can kill, and stress is most extreme near the end of a race.[2]

When the person is restrained, there is no end of the race. It is just fight against the restraints until there is no fight left.

The patient is vigorously struggling against the straps, even though he did cooperate and lie down when the officer asked him to. Just because he is not trying to hurt anyone does not mean that he is not struggling. This is a form of extreme exertion.

If you want to know what this is like, have someone strap you to a board. Then have them inject you with a large dose of epinephrine. Then you can try to get out by breaking the straps. Maybe you will not try very hard, but if you do put a lot of effort into this, you will quickly exhaust yourself. Maybe you will kill yourself. This is extreme exertion and the people involved are usually not in excellent physical shape.

I am just kidding about the epinephrine. While it would be one way to experience what the patients are experiencing, it is a really bad idea. Epinephrine might as well be a heart attack in a syringe.

Maybe this is the rhythm –

Maybe this is the rhythm –

Maybe it is some other rhythm.

We don’t know.

We can’t tell.

firetender has a video on his post, but there is a better video here. Unfortunately, I cannot embed it. This starts with the call to dispatch, then switches to video from the scene.

At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case. This is excellent communication and the right assessment.

What should EMS do for excited delirium?

Sedation.

What if that doesn’t work?

More sedation.

What if that doesn’t work?

Even more sedation until it does work or we run out of sedation.

At 5:37 (of the linked video) someone mentions, We’ve got Narcan and Haldol, or he said We gave Narcan and Haldol. I did not hear any other mention of EMS medications at any point, but the narrators drown out a lot of what is said.

Naloxone (Narcan) will only make this patient worse. If I run out of sedative, I want to give him morphine or fentanyl until he is sedated or until I run out of sedating medication to give. Opioids do have a sedating effect. Naloxone is for respiratory depression – where is there any sign of respiratory depression?[3] If we give naloxone to these patients, we may kill them.

Was naloxone given or just mentioned?

I don’t know, but if naloxone was given, too much was given.

Was haloperidol (Haldol) given or just mentioned?

I don’t know, but if haloperidol was given, not enough was given.

Here is a different example of excited delirium. This one was fatal. The patient was not attacking any of the police, he was only trying to keep from being restrained.
 


 

The treatment is sedation. Unfortunately, restraints generally need to be used to get the patient in a position where it is safe to give medication. A Taser is another way to stop the patient for long enough to get a lot of sedative into the patient.

Small doses kill, because they usually don’t even slow the patient down and may make the patient even more agitated. Yes, that is possible.

Excited delirium is a psychological and metabolic emergency. The metabolic emergency is what kills patients. This is not the time to try to get patients to tough it out the all-natural way.

Footnotes:

[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated link to PDF 7/23/2018.

[2] Philly Runners’ Deaths Point to Dangers of Extreme Stress on the Body – Between 6% & 17% of sudden cardiac deaths are associated with exertion
JEMS.com
Kia Gregory and Don Sapatkin
The Philadelphia Inquirer
Tuesday, November 22, 2011
Article

[3] Scopolamine Poisoning among Heroin Users — New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996
MMWR (Morbidity and Mortality Weekly Report).
Vol 45, No 22;457;
Free Full Text . . . . Free PDF

On March 16, 1995, eight persons were treated in the emergency department (ED) of a Bronx hospital for acute onset of agitation and hallucinations approximately 1 hour after “snorting” heroin. On physical examination, all these persons had clinical manifestations of anticholinergic toxicity (i.e., tachycardia, mild hypertension, dilated pupils, dry skin and mucous membranes, and diminished or absent bowel sounds); five had urinary retention. All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.

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Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions

In ACLS (Advanced Cardiac Life Support) one thing is consistent. Poisons are treated the same way before the patient codes, during the code, and after the code. Why?

Dr. James R. Roberts writes that there is no good reason for this –

Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.[1]

Toxicology is much more complicated than the ACLS guidelines.


American Association of Poison Control Centers

But everybody knows that any potential poisoning/overdose gets naloxone and the megacode is over with a successful resuscitation.

Any medical professional who suggests that naloxone (Narcan) is a resuscitation drug needs remediation or termination.

This is completely wrong and very dangerous thinking. This is magical thinking, which has no place in medicine. This is the kind of thinking that results in everyone being strapped to a backboard based on Mechanism Of Injury.

Don’t think, just do something dangerous.


Image credits – 123

Repeat the mindless sequence as often as necessary, until the desire to understand patient care has been destroyed.

With a dog, the bell ringing only leads to drooling, but medics are generally more dangerous than drooling doggies. Rabies is one way of producing drooling doggies that can compete with medics for ability to cause harm.

What do we expect to get, when we reward ignorance?

Routine naloxone use is a demonstration of incompetence.[2]

naloxone will not reverse cardiac arrest from an opioid.[1]

Only CPR and defibrillation seem to be life-saving. Not unexpectedly, this theme continues with the proclamation that there is no drug, antidote, or intervention that alters the outcome of cardiac arrest from a toxin.[1]

But what about Bicarb?

The use of sodium bicarbonate is not as common as the use of naloxone, but it is no better understood and sodium bicarbonate is a more dangerous drug. As with naloxone, ventilation is more important than medication. That is assuming that acidosis is the problem, which is usually not the case when sodium bicarbonate is given.

Hyperkalemia? Calcium is the treatment, not sodium bicarbonate. We avoid calcium, because we are told that calcium is dangerous and sodium bicarbonate is safe. This is nonsense.[3]

Although a few antidotes have the potential to rapidly neutralize or reverse the toxic effects of drugs in the still living, the majority of one’s arsenal to treat cardiorespiratory collapse secondary to a drug overdose is primarily basic support.[1]

Supportive care is the best treatment for opioid and benzodiazapine overdose when the patient is alive. That is even more true when the patient is dead. Too often we ignore supportive care in favor of magic.

Ignoring respiratory depression/arrest in order to give naloxone or flumazenil (Romazicon) is incompetence.

even flumazenil has “no role in the management of cardiac arrest” from benzodiazepines.[1]

Death from an overdose is quite unusual, probably less than two percent. Those patients who do succumb to their ingestion usually die in the prehospital phase or likely have their fatal course well ensconced before seeing the paramedic or clinician.[1]

If they are still alive when they meet us, we probably will not kill them – unless we do something thoughtlessly routine stupid.

The AHA recognizes that gastrointestinal decontamination, once a generic mainstay in managing any toxin, has a minimal role in changing the outcome of a toxic ingestion.[1]

We can make it difficult/impossible to manage the airway by routinely giving charcoal or ipecac. As I wrote yesterday, ipecac is a really bad idea.[4]

Resuscitation from poisonings with beta blockers, calcium channel blockers, digoxin, tricyclic antidepressants, cocaine, local anesthetics, carbon monoxide, cyanide and more are discussed in the article.

Go read the whole thing and learn a lot about the toxicologic management of resuscitation.

Footnotes:

[1] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
Emergency Medicine News:
October 2011 – Volume 33 – Issue 10 – pp 16-18
doi: 10.1097/01.EEM.0000406945.05619.ca
InFocus
Roberts, James R. MD
Article

[2] Naloxone
Rogue Medic
The problems with naloxone in four parts –

Narcan Solves Riddle – Part I
Narcan Solves Riddle – Part II
Narcan Solves Riddle – Part III
Narcan Solves Riddle – Part IV

[3] EMS 12 Lead Bradycardia Post – Part II
Rogue Medic
Article

[4] Ipecac for Tricyclic Antidepressant Overdose
Rogue Medic
Article

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EMS Needs to Be a Separate Medical Specialty – Now – Part I

Ckemtp documents one of the major problems in EMS in Every Day EMS Ethics – Self Medical Direction?

How are we supposed to deal with bad protocols, when some medical directors would rather endanger patients, than improve patient care?

Which is more ethical?

A. Follow the protocol, even though it endangers patients. I am only following orders. As long as I am following the protocol orders I am not responsible for anything that I do.

B. Violate the protocol, but document it accurately, knowing that my medical director is interested in what is best for the patient, not what is best for the protocol. My medical director makes it clear that he will support me, as long as I am acting in the best interest of the patient.

C. Violate the protocol, but document it accurately. Unlike in scenario B., knowing that my medical director thinks that a medic’s place is under the bus. Knowing that my authorization to treat patients is likely to be revoked, unless I apologize for having the arrogance to question what the medical director put in the protocol. Also, I must promise to never again protect the patient from the medical director. I may end up going to court over this, but the jury is chosen because they are unfamiliar with medicine, not because they have a clue. The medical director will be presented as the expert, while I am just the arrogant know it all.

D. I can titrate the dose of medication to the response of the patient. Stop when the desired effect appears to have been produced, realizing that things change and more may need to be given, if indicated. If my protocol does not include a rate of administration, can it really be said that I have violated protocol, by giving the medication too slowly?

E. Transport without giving the dangerous dose. Transfer care to the physician explaining that, I am incredibly clumsy and can’t imagine why I could not manage to complete a simple task, such as poisoning my patient. Mea culpa. Mea maxima culpa. Meh.

Since Ckemtp is writing about naloxone (Narcan), it is fortunate that I have written just a little bit about this – from my very first post, to one where I describe what may be the most effective way to educate a physician incompetent in the use of naloxone, to a bunch of other naloxone posts – here, here, here, here, here, here, here, here, and here. That probably is most of them, not that I have much to say on naloxone.

In answer to the inevitable comments that the medical director, even an absentee medical director, has spent years in medical school and residency. How dare I question the judgment of a physician?

First. I would hope that anyone that well educated would put the welfare of the patient above the welfare of the protocol.

Yes, protocols are important. However, if protocols are to be respected, they need to keep up with the evidence. Anything less than that just demonstrates that the physician is not acting in the best interest of the patients. The purpose of the protocol is to protect the patient. Making the protocol the weapon to hurt the patient, because the protocol is there to protect the patient, is insanely bureaucratic.

If the physician is willing to harm patients, just to make a point, or just to have his own style of control, that is not an example of patient care to be respected.

Second. Ignorance, in spite of all of that education, is nothing to brag about.

Third. This physician is advocating abusing patients. And people are defending the physician. Why are people defending the abuse of patients?

Fourth. Joseph Mengele was a physician. There is nothing about being a physician that makes one perfect, or ethical, or right. We need for good physicians to strongly oppose the bad physicians. First, both medics and other physicians should try to reason with the dangerous medical director. As I pointed out EMS is not well understood by many emergency physicians.

Fifth. The 8th Law – Half of what is taught in medical school is wrong, but nobody knows which half. Declarations of a Dinosaur – 10 Laws I’ve Learned as a Family Doctor, by Lucy E. Hornstein, MD, who writes Musings of a Dinosaur. There are links to purchase the book in her sidebar. This could explain why some medical directors do not live up to expectations.

Titration of medication is not avant-garde. Paracelsus (he lived from 1493 – 1541, so this is not exactly new) wrote –

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

To give something in a quantity that is inappropriate is to poison the patient.

If I document good patient care that conflicts with a given protocol, I need to have a medical director, who understands good patient care. I need a medical director, who understands Emergency Medical Services. This is one of the reasons that there needs to be board certification for physicians in the medical specialty of EMS.

Separate from emergency medicine. Emergency medicine is as different from EMS as internal medicine is different from emergency medicine. One may do a good job working in the other specialty, but do you really want to be cared for by someone moonlighting in a specialty in which they are not trained?

EMS needs to be its own board certified medical specialty, because there are too many emergency physicians who just do not understand prehospital care. Too many emergency physicians who just do not understand medical direction/medical oversight.

Even those, who have worked in EMS may find that things have significantly changed since they were working the streets, or they may find that the tried and true principle of Mother may I? calls for medical command permission to provide emergency treatment are counterproductive to good patient care. Mother may I? medical command only encourages medical directors to feel comfortable allowing dangerous paramedics to work.

These medical directors claim that, I know that Medic X is dangerous, but as long as he has to call for everything, how much harm can he do? Who is more dangerous, Medic X or the medical director who sets loose a service full of Medic Xs on a defenseless population – a population in need of competent emergency care?

The medical director is there to defend the population, but the Mother may I? calls for medical command endanger the population.

Of course, I would never advocate documenting care inaccurately, because that would allow the state to pull my medic card. I must follow the protocol. I must document accurate compliance with the protocol. We must respect that when the state insists that I do something unethical, it is their position that it is unethical not to perform the unethical behavior.

Paramedic Yossarian reporting for duty.

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When Michael Jackson Is The Patient – A Call That Everyone Will Criticize

While there are probably people going to write about the coverage of this being like Elvis all over again, I am just interested in the EMS aspects of what happened.

The 911 call was simple, but it did raise one question for me. Was CPR being done on a bed?

CPR on a surface that absorbs some of the force of compressions, decreases the effect of the compressions. A hard surface that does not move is an important component of effective CPR.

There is a report that CPR had been in progress for an extended period of time and that lidocaine might have been used. No mention of epinephrine, not that either would have changed anything. These drugs, amiodarone as well, are nothing but plumage. ACLS has us focusing on things that are irrelevant.

Marc Eckstein, MD, MPH, FACEP, Medical Director of the Los Angeles Fire Department, told JEMS.com. “They found Mr. Jackson in full cardiac arrest with CPR in progress.”

“LAFD members immediately took over CPR and intiated both basic and advanced life support interventions,” Eckstein continued. “They aggressively attempted resuscitation on scene for approximately 30 minutes, and after consultation with on-line medical control at the UCLA base station, they continued resuscitative efforts during the short transport to the UCLA emergency department. There was no change in the patient’s status during his prehospital course.”[1]

What about Narcan (naloxone)? Since he is reported to have been receiving Demerol (meperidine) wouldn’t Narcan be a life saver?

I have written here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, and here on what naloxone does. Perhaps more specifically these are about what naloxone does not do and why naloxone is rarely the first choice of intervention for opioid overdose.

What naloxone does not do is make a difference when the patient is already receiving artificial ventilation, as is the case here. This would be one of the cases of cardiac arrest where ventilation is important. The focus on continuous compressions is not appropriate when it appears that the arrest is due to respiratory causes. Naloxone does not charm the heart beat into returning. Naloxone does not persuade the brain to function again.

This patient was dead. EMS wanted to pronounce him on scene, but the patient’s private physician insisted that futile resuscitation efforts be continued.

What do you mean futile?

The patient is reported to have been asystolic (my conclusion based on the description of lack of response and desire to pronounce on scene) and unresponsive to half an hour of full resuscitative attempts. I do not know the specifics, but Los Angeles protocols are likely to be very close to the ACLS guidelines. There is nothing about the circumstances that suggests any of the reversible cause of cardiac arrest.

What about OverDose?

It was already being treated by ventilating the patient.

But opioids also cause vasodilation!

And EMS has probably pushed enough epinephrine to make any patient, with a chance at resuscitation, hypertensive and hyperactive. Vasodilation is not a concern. The reason for the lack of blood pressure is the lack of a heart rate, not histamine induced vasodilation.

Demerol toxicity can also lead to seizures, because of accumulation of a toxic metabolite in the body.

This is true, but seizures would have been an improvement at this point. Cadavers do not have to worry about toxicity.

Then why did they work on him for so long at the hospital?

Famous people with lots of money may pursue ridiculous law suits much longer than other people. When a lawyer, who works on a percentage basis, sees no reason to continue, the lawyer will find a way to drop the case. When the client is paying out of pocket, pockets that contain hundreds of millions of dollars, and the client does not care how much it costs, and the client has unreasonable expectations, things will be done differently. The patient’s personal physician was probably part of the reason. I have never heard of any case of resuscitation being continued even half as long as this, except in the case of intermittent return of pulses or a potentially reversible cause of cardiac arrest (such as hypothermia).

On scene, the patient’s doctor is one person, who generally outranks EMS. The same would be true for a hospitalized patient being transferred. As long as the patient’s doctor is present, the patient’s doctor has final say on medical decisions. That may be different in different states. Generally, a doctor needs to get permission from OLMC (On Line Medical Command) to take over treatment decisions from EMS. Part of that is agreeing to accompany the patient to the hospital. The patient’s private physician is probably not covered by this. In a VIP case, like this, I would expect the physician to want to accompany the patient. I doubt that OLMC would want to tell the private physician to let EMS run things, unless the private physician is causing problems other than demanding that care be continued. That is one thing OLMC is unlikely to fight about with the doctor who is there and is the patient’s doctor.

What about the pictures that were published? How could EMS let that happen? That is a HIPAA violation!

The primary responsibility of EMS is to take care of the patient. Privacy comes second. With a team of private security on scene, I would be delegating all privacy management to the people who are paid around the clock to protect his privacy. They also have a responsibility above privacy – his safety. They have already done all they are going to be able to do to address his safety, so privacy may be their primary remaining job.

It is unfortunate that there is a picture of the resuscitation efforts. As with Jett Travolta, the fame, or money, or both, or something else, caused someone to decide that this was a good time to get a picture to share with the gossip rags. Others have republished the picture, because it is already out there.

The blame should be addressed primarily at the people who took the picture, sold the picture, bought the picture, and first distributed the picture. Much less important is blaming those in security, or EMS, who might have prevented this. This kind of picture gets out because there is a huge market for it. The publisher will make a killing in both sales volume and reputation. The purchasers may not be the majority of the population, but there are enough to make this very profitable. We have met the enemy . . . . My doesn’t that reflection make us look unattractive.

So, blame EMS?

No. I don’t even have real criticism for security. They are probably not used to dealing with a death. Not like that.

Blame EMS for not reversing an opioid overdose?

He was already dead. Not much chance of a good outcome when an opioid overdose leads to cardiac arrest. He had probably been receiving inadequate CPR, so what is there to work with in a situation that deteriorates rapidly over just a few minutes.

What about the Demerol?

I will have to write a follow up on the use of Demerol. There is a lot to write.

Again, STATter 911 is the source that seems most current on EMS aspects of this case.

Footnotes:

^ 1 Michael Jackson EMS Response Details Emerge
Posted by Firefighter Nation WebChief on June 26, 2009 at 3:14pm in Fire/Rescue News
View Discussions
citing JEMS.com
Article

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Narcan Solves Riddle – Part IV

OK a double Normal Sinus Rhythm post this week. 🙂

This week, again, there is no theme. Read the rest of the NSR Blog posts at NSR Week 14.

This continues from Part I, Part II, and Part III. One of the problems with people claiming that naloxone is diagnostic, or that there is something to be gained by drawing conclusions from a response to naloxone, is that it is just bad logic.

Nassim Nicholas Taleb wrote about this in his book Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets and in his latest book The Black Swan: The Impact of the Highly Improbable. He paraphrases the conclusion –

How many white swans does one need to observe before inferring that all swans are white and that there are no black swans? Hundreds? Thousands? The problem is that we do not know where to start[1]

While we do not care that much about swans in EMS, the occasional dying swan act is just something we occasionally need to deal with. The problem of drawing inappropriate conclusions may be our biggest problem. Claiming that naloxone is diagnostic is not any different from claiming that all swans are white.

I have seen many swans.

OK.

They were all white.

Still OK.

Therefore all swans are white.

That may be true, but there is no way that we can prove this.

How many swans do we need to see to be able to draw this conclusion?

All of them.

Not 51%.

Not 90%.

Not 99%.

Not 99 and 44/100ths%.

Not 99.999%.

We need to see all of them.

So we round up all of the swans in the world and observe that they are all white. Then we are sure.

No.

Still not OK.

We also have to examine all past swans and all future swans.

There may have been a species of non-white swans that became extinct.

There may be a genetic mutation, or there may be genetic manipulation, that would lead to a non-white swan.

Therefore, how many administrations of naloxone to opioid-free people do you need to observe – without response – to be able to state that naloxone is diagnostic for opioids?

All of them.

All in the past.

All in the future.

We can conclude that it seems that naloxone is a way of identifying opioid consumers, but that we reserve judgment on something that cannot be proven.

So there is no way to prove this?

That’s right.

But there is a way to disprove this.

Why disprove it?

Because bad logic leads us to make mistakes.

In EMS, it is fortunate that we are only playing with patients’ lives. So why worry about making bad decisions? Especially, since this is not a decision likely to kill anyone?

Even though this is not likely to kill anyone, similar logic is not so benign.

So, how do we disprove something like this?

How many non-white swans would it take to prove that not all swans are white?

At least one.

It is such a fragile and useless conclusion, that to disprove it requires one and only one example of failure of the supposed rule.

An exception does not confirm a rule. An exception demonstrates that the rule is faulty.[2]

Farther down in the same paragraph, Dr. Taleb provides the answer –

Note that the Black Swan is not just a metaphor: until the discovery of Australia common belief held that all swans were white; such belief was shattered with the sighting of the first cygnus atratus.[1]


How many ways do I need to demonstrate that it is foolish to conclude what a person may have consumed based on their apparent response to a medication – a medication that has a long history of being wrong?

Well the patients who were postictal (recovering from a seizure) were clearly not patients who should have received naloxone.

Is that because a competent assessment is better at diagnosing the presence of opioids?

That eliminates any reason for using naloxone diagnostically, doesn’t it?

Seizures can occur secondary to opioid use. Stroke/TIA (Transient Ischemic Attack) can also appear to respond to naloxone without any opioid consumption. Alcohol can respond to naloxone. Clonidine can respond to naloxone. These are not opioids.

Squirting naloxone in the veins, muscles, nares, tongue, . . . of every unconscious person does not diagnose the cause of unconsciousness.

This drug abuse (abuse of naloxone by EMS) may mislead us.

If we give naloxone to a person who had a seizure, the patient appears to respond, and we then decide to treat the patient as a drug addict, is there a possibility for harm to the patient? Aren’t we supposed to treat seizure patients for seizure, rather than for an imaginary drug overdose?

If we give naloxone to a person who had a stroke, the patient appears to respond, and we then decide to treat the patient as a drug addict, is there a possibility for harm to the patient?

All this is doing is teaching us, or reinforcing, bad diagnostic skills.

Aren’t we supposed to be doing just the opposite?

Science is only valid if there is a way of disproving the hypothesis. Anything that cannot be disproved is not science. This use of naloxone to diagnose is not science. This use of naloxone to diagnose is pseudoscience and needs to be opposed.

Pseudoscience kills.

Footnotes:

[1] The Roots of Unfairness: the Black Swan in Arts and Literature
Nassim Nicholas Taleb
FooledByRandomness.com
Free PDF

[2] What’s the meaning of the expression, “That’s the exception that proves the rule?”
A Straight Dope Classic from Cecil’s Storehouse of Human Knowledge
Article

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