Overdose Treatment - One Perspective

Wandering a bit from the recent All Cardiac - All of the Time drift of Paramedicine 101, but not entirely, I must point out an excellent post on Heroin Overdoses by a blogger, who really is much more imaginative than that post title suggests - Too Old To Work, Too Young to Retire. He is just as direct as the title suggests.

Here is an example of education on junkie slang. It is both translated to everyday English and comes with an explanation of the most effective and most appropriate treatment.

commonly known as "nodding off" or being "on the nod". The person is usually easily woken up by either a shake on their shoulder or speaking to them loudly. Despite what some in EMS think, this is NOT an overdose. Because it is the desired effect, I refer to this as "a dose".

He describes the protocol that is in place where he works. His protocol uses respiratory depression as the criterion for treatment with naloxone (Narcan). Some of us have protocols that require treatment with naloxone for Altered Mental Status. I am not in favor of treating opioid overdoses under Altered Mental Status protocols, because this discourages the medic from delivering appropriate care. In stead, the medic ends up delivering vending machine care.

Enter minimal diagnostic criteria _____, remember to use only approved EMS terminology (the protocol vending machine does not recognize unapproved terminology), press Enter, and out pops a treatment. Eureka! No Fuss, No Muss, No Thought, No Possibility For Error. At least, this is the way that many seem to design protocols. Of course, the word diagnostic would not be in the list of approved terminology.

If we are designing a protocol with Foolproof in mind, aren't we designing protocols to encourage the hiring of fools? How can we deny that we expect fools to use the protocols, if we are designing the protocols with fools in mind? We are designing protocols to prevent fools from doing too much damage, while using those protocols. Wouldn't it be better to just keep the fools from being authorized to poison patients?

There is a great article by Dr. Bledsoe on the error of using a set treatment for every unconscious patient.[1]

TOTWTYTR points out the use of other diagnostic information in coming to the conclusion of heroin overdose. In addition to the respiratory depression, needle marks, pinpoint pupils, being in a shooting gallery, the presence of injection supplies, . . . are just some of the information that would lead a competent medic to use naloxone in treating this patient. Pennsylvania has a pretty good example of this in their protocols.[2]

With such a patient, my goal is not awake and alert, but breathing adequately. True, they will not have a GCS[3] of 15, but that is where the word competent becomes important. Were we called to the scene because a heroin user was sleeping (not awake), or because a heroin user could not go out and steal something to pay for more drugs (not alert enough to act as a lookout), or because a heroin user was not breathing adequately?

How awake do we want the patient to be?

How alert do we want the patient to be?

How much do we want to endanger EMS crews, just to have the vital signs part of the paperwork look pretty?

Is it possible that an HOD (Heroin OverDose) has a stroke at the same time? Gosh, injecting various impure and not exactly FDA approved solutions into the veins could result in something that should not be in the brain, ending up in the brain. And I am not referring to the heroin, but particles that do not become fully dissolved in the solution that is injected, or particles that precipitate out of solution at some point. These would not be described as good in the brain. What is baseline function of the addicted brain? Is it always GCS = 15? Can we identify signs of a stroke, even if the patient's GCS 15? Yes. Why do we think we could not?

Reading TOTWTYTR's blog is a good way to avoid the dumbing down of EMS. He does not only mention the shortcomings of EMS in this post, but points out the abuse of pulse oximetry in the hands of a nurse. Is he just looking for an opportunity to criticize nurses? No. He is pointing out that this is somebody who should not be a nurse - perhaps a Faux Nurse. No more representative of competent nurses than a Faux Paramedic (Medic X) would be representative of competent medics.

Anyway. Go read the whole thing. It is longer than his usual post (bad kettle), but it is very informative and entertaining.


^ 1 No more coma cocktails. Using science to dispel myths & improve patient care.
Bledsoe BE.
JEMS. 2002 Nov;27(11):54-60.
PMID: 12483195 [PubMed - indexed for MEDLINE]
The Pubmed link is to the abstract. For the full article as a pdf, click below.
Free PDF

^ 2 Altered Level of Consciousness
Pennsylvania Adult Statewide ALS Protocol
Note # 6
Pages 78/121 and 79/121 enter 78 in the page count window.
Nov. 2008 posting of PA ALS Protocols in PDF

^ 3 Glasgow Coma Scale/Score



Walt Trachim said...

Between you guys and TOTWTYTR I think you all nailed it. And I know you saw my comment over on his blog...

One thing I wanted to expand on a little bit is the subject of "foolproof" protocols. You took a big bite out of that apple also; anyone who's been around our line of work for any length of time knows that there are more fools in it than the rest of us would like to see. And it is scary that the protocols we work under in different places are written for the lowest common denominator.

Because I work in multiple jurisdictions in two different states I see huge differences in the way that protocols are written and implemented. New Hampshire is a bit different than Massachusetts in that there is an awful lot that Paramedics can do under standing orders state-wide. Massachusetts is broken up into 5 regions, and things are done differently in each one. In my view, that has the potential to be really confusing if you don't have a good handle on the skilss you're supposed to be proficient at.

My personal opinion on this is simple: while it's good to give Paramedics as much liberty to do their job in the best way possible, it can work the other way as well, like a rope one can hang themselves with.

Bledsoe's article, by the way, is excellent. Thank you for including the link to it.

Rogue Medic said...

Walt Trachim,

Dr. Bledsoe's site is an excellent resource. He has many articles available for free there. It is on my sidebar, which is kind of broken up into resource sites and blog sites, but is becoming disorganized depending on what mood I am in, when I add a link.

Because I work in multiple jurisdictions in two different states I see huge differences in the way that protocols are written and implemented.

I have had jobs in 5 different regions, with 5 different sets of protocols, at the same time. Did I know all of the protocols. No. I did what was best for the patient. I knew enough to realize that in 2 of the regions, I had to call for just about anything that might be good for the patient, so I would call first. The main difference in the protocols was when you need to make the Mother may I call. It isn't as if the doctors answering the phone are generally familiar with the protocols, especially when they regularly receive patients from different regions.

I think that kind of experience is one of the things that helps to make it clear that there are huge variations in the protocols from service to service, county to county, region to region, state to state. Most of these variations are not due to differences between patient populations, but quality of medical oversight. I believe that the medical directors are the number one variable in the differences among protocols.

Patient care varies more on the whim of doctors than anything else.

Something needs to be done to make medical directors aware of the research that is relevant.

Something needs to be done to make it possible for all services to afford excellent medical direction.

Something needs to be done to recognize the value of competent medical direction.

There is no reason for EMS to expect medical directors to donate their time. Competent medical direction requires too much involvement by the medical director. Expecting free medical direction to be anything other than dangerous to the patients is delusional.

There may be some free medical directors, who are good, but when you nickel and dime your system to death, you nickel and dime patients to death, too.

The most expensive things you ever receive will be the ones you get for free.

People become all sorts of stupid, when they see the word FREE.

Shaggy said...

So, RM, what is your point you are trying to convey re protocols? Sure the old mother-may-Is are not beneficial to most, but they are a thing of the past, for the most part.
Our medical direction gives us a lot of leeway. We all know that sometimes one must deviate from protocols because of obvious reasons. I admit, our state protocols express that in that event, we are to call first. What experienced medics do that? I don't. I document as such and am still relatively left alone or at the most, or at least asked if I knew there was no protocol for what I did. If the treatment was within the best interest of the patient, and was appropriate, it ends there. Some can argue for or against this. Whatever.
But until we can change the educational standards and raise the bar of what we expect of our providers, we must continue to have protocols that protect the patient.
As a caveat, I WILL say, I have seen protocols that were appropriately followed that were not appropriate for the patient, but the protocols were followed because...the providers had to follow the protocol ie. giving NTG and lasix to normotensive patients with basilar rales just because the patient has a history of CHF and mild chronic dyspnea, NTG to chest pain patients despite EKG findings of right sided MI, or the infamous atropine to the bradycardic MI patient with chest pain-"symptomatic bradycardia", yada yada yada. A problem where the medic looks for the most appropriate protocol and follows it to a "t" or the lack of clinical thinking skills, or both.