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

- Rogue Medic

The Joy of Naloxone (Narcan)

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.