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Ambulance: 3 EMS Models of Opiate Intervention

Written by RSS Poster Medic Scribe

Opiate users who suffer a non-fatal overdose are at the highest risk for having a fatal overdose.

Many of these people are hard to reach by traditional substance use and health care professionals.  EMS can make a difference with this population.

Whether the patient refuses further care and transport at the scene after being resuscitated or whether they go to the ED and then check out AMA, EMS has the opportunity to intervene.  Here are three models an EMS system should consider.

Provide Treatment Information. 

If there is a toll-free number for substance use help in your state, as there is in Connecticut, give them that number, or give the number of the local harm reduction coalition.

In Connecticut call 1-800-563-4086.

Department of Mental Health and Addiction Services Access Line for Opioid Users

Greater Hartford Harm Reduction Coalition

Give your patient information on where to obtain treatment, and/or if they are not ready for treatment, provide them with information on where they or their family members can...

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Ambulance: Don’t Use Alone

Written by RSS Poster Medic Scribe

61 people died of heroin overdoses in Hartford in 2016 (according to numbers released by the state Medical Examiner’s office on friday), up from 37 in 2015.  Based on the first six months of the year, the state estimated 888 people would die statewide, but when the final numbers came out last Friday, the number was  917.  This represents a 25% increase over last year, which was itself a 11% increase over the year before.  Of the 917 who died, 479 had Fentanyl in their system.  In 2012 there were only 14 Fentanyl deaths in Connecticut.  Here are the year by year numbers:

Fentanyl Deaths in Connecticut

2012-14

2013-37

2014-75

2015-188

2016-479

Last week I responded to an unresponsive in an area known for drug overdoses.  When I arrived in the 2nd floor apartment, I heard  a person say the man had a pacemaker.  I found a man on his side on a mattress in the living room.  His head was bluish purple, he had vomit on the side of his mouth and pillow.  He was not breathing,  I felt for a pulse on his thick neck, but felt nothing.  We...

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Ambulance: Harm Reduction

Written by RSS Poster Medic Scribe

Two words people in EMS interested in battling the opiate overdose epidemic should know are “HARM REDUCTION.”

According to the Harm Reduction Coalition, harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.

Harm reduction “accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.”

We in EMS like to respond to calls where a crisis is happening and we fix it and the person is better and can return to their normal life.   Unfortunately, EMS calls are rarely that simple.

We give someone Narcan and then we find the same person oded later that day.  Does that mean, we stop trying to save them?  Or does it mean we have to find other ways to get through to them?

If we can’t stop someone from using drugs that could kill them, we can at least try to help them mitigate the risks.

Across the country harm reduction organizations run needle exchange programs,...

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Ambulance: Novel Vagal Maneuver

Written by RSS Poster Medic Scribe

I never had great luck with vagal maneuvers.  Admittedly when I was a new medic, I didn’t particularly want them to work.  I wanted to give Adenosine, and watch the strip suddenly go asystole and then some wild funky beats before correcting to a nice sinus tack in the 120’s, way better than the 200’s I encountered.  Paramedic as savior!  I remember once how upset I was when I encountered a man in an PSVT in a doctor’s office.  As I got out my IV kit, the doctor ordered me to just take the patient to the hospital so they could see the rhythm for themselves.  Okay, I said, fully determined to work my magic in the ambulance.  Unfortunately for me, carrying the man down the stairs, caused a brief jostle and wallah, he was out of the PSVT.  Drat.

In time though I collected the experience of patients’ extreme uncomfortableness with Adenosine.  They’d clutch their chests in terror as their hearts stopped.  Two actually told me they would rather be shocked than get that drug.  Another pleaded with me not to give it to her, and even...

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Ambulance: Narcan 4mg IN

Written by RSS Poster Medic Scribe

download

I was a big initial fan of the intranasal atomizers both for pain management and opiate overdoses.  I liked them for pain management for their quick access.  I often gave an intranasal dose, and then after getting an IV, gave the rest IV.  Overtime I noticed quite a difference in response between the two methods.  IN might touch them; IV almost always worked.  Recently I have switched to IM for the quick first dose.  Sure it involves a needle stick, but the onset is quicker and it seems more effective.

I have continued to use intranasal Naloxone as my first line for opiate overdose accompanied, of course, by bag valve ventilation, but I have been having second thoughts about the IN route of late.  I have always preached patience, and when I give Narcan IN, my patience is usually always rewarded with a calm, almost placid patient.  Many of my peers have told me they prefer 1.2 mg IM as their starting dose.  That’s what I used before IN came out.  True, it does return their breathing sooner and almost always wakes them, but sometimes it...

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Ambulance: Hear the Drumming

Written by RSS Poster Medic Scribe

Another three dead of heroin overdoses in Hartford in the last 16 hours.  The slaughter continues.  Hartford led the state in overdose deaths in 2015 with 56.  The 2016 numbers, which are not complete, are estimated to be in the high 70s.  Already there have been 5 known heroin deaths in 2016.   I recently did a cardiac arrest of a male in his 40’s just out of rehab, found dead on the couch.  No heroin paraphernalia was seen, but who’s to say the scene wasn’t sanitized before we got there or maybe he snorted outside and walked into the house and collapsed.  Not certain if he ended up as a medical examiner case, but if he did, the evidence will be in the blood, and his name will be added to the tally.

Next week, at our hospital EMS CME, a death investigator from the office of the state Medical Examiner will be speaking to us about heroin and fentanyl.  I am very excited to hear her talk.

I am encouraged that people are the crisis seriously.  From police to health care workers to elected representatives, an extraordinary number of people...

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Ambulance: Neuro EMS

Written by RSS Poster Medic Scribe

Check out the great post on Neuro EMS:

30 Seconds to Understanding Drug Addiction

“EMS is at the forefront of emergency medicine therefore we should be at the forefront of shattering mental health stigma and providing compassionate, non-judgemental care.”

Bravo!



Ambulance: Snowbank

Written by RSS Poster Medic Scribe

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It is six in the morning and we get called for an overdose outside.  The address is not a surprise — a side street off Park.  Yet when we arrive, we find no one.  We are about to clear when a police officer who has also responded finds a backpack in the snow and sure enough coming down the street is a man who seems somewhat confused.  One side of him is dripping wet as if he had been laying in the snow.  He has come to claim his backpack.  I ask him why half his clothes are soaking wet.  He hesitates a moment, and then says he was helping a friend shovel.  This answer makes no sense.  It is after all six in the morning and the snowstorm was the day before, ending well before sunset.  

We tell him we were called for an overdose, but he knows nothing about it.   I ask him if he has been using drugs in the last several hours.   “Ohhh, nooo,” he says.  “Well, maybe seven years ago, but not for s long time.”

He knows the date and his name and has no interest in going to the hospital.   I suggest we take him to the hospital anyway.  He...

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Ambulance: Happy

Written by RSS Poster Medic Scribe

happy

I ask my patients who are addicted to heroin how they got started.  Many tell the same tale.  Injury.  Prescription for Percocet or Oxycontin.  They got addicted.  Prescription either went away or couldn’t keep up with their growing tolerance.  They started buying pills on the street.  Then they learned heroin was cheaper and worked even better and was more widely available.

But not all people become addicted to heroin this way.  Here are three patients’ stories.

Shelly worked in a restaurant.  She was a twenty-eight year old single mom, who was going through a hard time.  Her daughter’s father had left them and she was staying with her mother and stepdad who she felt were always judging her poorly.  She noticed one her coworkers was happy all the time, no matter what was going on in his life.  She asked him how that was.  He said he used heroin.  So she tried it with him one night.  And she had never felt so good.  All her cares when away.  Three years later I am taking her from jail to the hospital for nausea.  She was arrested for...

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Ambulance: Who Narcan Saves

Written by RSS Poster Medic Scribe

photo (27)

I was at a recent meeting of a statewide opiate overdose working group, composed of a wide variety of community stakeholders all committed to helping curb the crisis, when I heard one woman say our goal should be Narcan in every medicine cabinet. Certainly Narcan should be in the homes of any person with a history of opiate use.

Narcan saves lives.

But it is important for those who view Narcan as a magic bullet to understand Narcan does not save a life every time it is used.  It is irresponsible for those who know better to issue press releases equating the number of Narcan uses by their organizations with the same number of lives saved.

Narcan does not save patients in true cardiac arrest.

Narcan does not save patients with coma not of opiate etiology.

Narcan does not instantly restore adequate ventilations in those patients who may still be breathing, but who are hypoventilating.  If not given in time, Narcan may not save these people unless someone is there to ventilate them.

Narcan does not save patients who are merely dosed on opiates,...

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Latest Medic Scribe Stories

3 EMS Models of Opiate Intervention
Don’t Use Alone
Harm Reduction
Novel Vagal Maneuver
Narcan 4mg IN

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