Northern Westchester Heroin Overdoses

[x635 4,066]

I've been reading about all the overdoses in Northern Westchester on LoHud.com. All seem to be a bad batch of Heroin going around, which happens every fews years.

Which leads me to the question- should first responders (PD,EMS,Fire) be equipped with Narcan that can be delivered via the nasal route? Heck, some cities give it out to junkies to prevent heroin overdoses they may come upon. Although it doesn't rule out an IV injection, it could help buy some time, especially when ALS is coming from a distance.

Boston did a comprehensive study on this:

http://www.bphc.org/programs/aptrss/ourservices/preventionandharmreduction/Forms%20%20Documents/Boston%20OD%20prevention%20pilot%20report%20to%20BOD.16April2007.pdf

[x129K 1,393]

Keep the Vitamin N in the hands of the medics...firemen and cops have enough on their plates already, and it grows each day..we have become so specialized that the basic skills of firefighting suffer...

*disclaimer; I hate EMS right now...but do see PFD's points below...

Edited March 28, 2011 by Bullseye

[PFDRes47cue 653]

I would prefer BLS providers be able to check blood sugar first. Narcan delivered nasally route would be a nice second step.

[ONEEYEDMIC 68]

If PD/FD knows the signs over an overdose, Narcan would be a great 1st line drug. I mean I have watched trained EMT's give instant glucose to patients with an unsecured airway! Just saying there happens to be many trained LEO's/FF's. The heroin epidemic has been a problem in Northern West for a long time now!

[joetnymedic 43]

couple that with new haven and bridgeport and their latest batch of bad pcp

[Bnechis 3,961]

How about before we give BLS units meds, we require they need to respond to calls after the 1st tone out and within national standards for dispatch and turnout times. Note I will let the response time slide, because as stated, some of the distances are far (and the response time standard is based on urban/suburban).

[x635 4,066]

How about before we give BLS units meds, we require they need to respond to calls after the 1st tone out and within national standards for dispatch and turnout times. Note I will let the response time slide, because as stated, some of the distances are far (and the response time standard is based on urban/suburban).

That's why equpping Police Officers with the narcan would be important-they are always on the road and mostly always first on scene in these communities.

If other major cities are letting this be administered by civilians with minimal training, then there's absolutely no reason why it can't be allowed in Westchester, especially with all the credible research available. And if someone does overdose on heroin, there needs to be some leniecy on the victim by law enforcement so people call immediately without the fear of getting arrested.

[Goose 188]

I would prefer BLS providers be able to check blood sugar first. Narcan delivered nasally route would be a nice second step.

EMTs are allowed to check blood sugars.

http://www.werems.org/pdf/BLS%20Glucometry%20Approval%20Steps.pdf

While narcan is a generally safe drug i don't really giving it to PD of FD (who don't always respond on EMS calls) makes much sense. As far as BLS providers....i still don't know. I was taught, and practice, the titration of narcan at intervals of .4mg until respiratory rate has improved to a life-sustatning rate & quality. Blasting someone with 2mg will either create for a violent situation or create the potential for an airway obstruction. It doesn't appear you get that ability w/ IN administration. Besides, if these people are found in asystolic arrest.....narcan isn't going to save them.

Not to mention..Westchester is heavily saturated with paramedics....and don't a lot of those northern westchester ALS units arrive before (sometimes WAY before) a bus?

Edited March 29, 2011 by Goose

[PFDRes47cue 653]

EMTs are allowed to check blood sugars.

http://www.werems.or...val%20Steps.pdf

While narcan is a generally safe drug i don't really giving it to PD of FD (who don't always respond on EMS calls) makes much sense. As far as BLS providers....i still don't know. I was taught, and practice, the titration of narcan at intervals of .4mg until respiratory rate has improved to a life-sustatning rate & quality. Blasting someone with 2mg will either create for a violent situation or create the potential for an airway obstruction. It doesn't appear you get that ability w/ IN administration. Besides, if these people are found in asystolic arrest.....narcan isn't going to save them.

Not to mention..Westchester is heavily saturated with paramedics....and don't a lot of those northern westchester ALS units arrive before (sometimes WAY before) a bus?

Very true...I forgot about this since my agency is not doing so yet. My apologies for the brain fart.

[Bnechis 3,961]

Our BLS 1st Responders are trained and equipped with Epi pens to help patients in anaphylaxis and albuterol to treat asthma. Anyone suffering from anaphylaxis or asthma generally has little or no control over these medical conditions.

While this may sound a little cold, but at what point do we stop taking responsability for the stupidity of others? You play russian roulet with heroin and you may take a bullet. Why is it our responsibility to protect you from yourself?

I have no problem with ALS units providing this service, but we have limited resources and its getting to the point that if we add something new, we need to take something away.

[x635 4,066]

While narcan is a generally safe drug i don't really giving it to PD of FD (who don't always respond on EMS calls) makes much sense. As far as BLS providers....i still don't know. I was taught, and practice, the titration of narcan at intervals of .4mg until respiratory rate has improved to a life-sustatning rate & quality. Blasting someone with 2mg will either create for a violent situation or create the potential for an airway obstruction. It doesn't appear you get that ability w/ IN administration. Besides, if these people are found in asystolic arrest.....narcan isn't going to save them.

If a patient is in asystole and given IV Narcan with good CPR, then their chances of survival increase greatly.

IV Narcan is different then nasal narcan. It absorbs in a much different way, and has been proven to save lives without significant side effects.

Regardless, there is bad heroin going around, and every tool should be used to combat this. It's not our place to judge these people for what they have done to themselves, but we're not God either. It's not our job to judge people- it's our job to save lives. And this will give the patient that extra edge where time is critical, so why isn't this being done?

People who have gone through these bad heroin going around situations know....that you sometimes even run out of Narcan because there are so many....I remember this situation happening in Yonkers when I was an EMT.....we responded to the projects on School Street several times on one shift for the same thing.

And the correct way to titrate Narcan is enough so they can walk to the bus......

[Bnechis 3,961]

Regardless, there is bad heroin going around, and every tool should be used to combat this.

Narcan is not a tool to fight the use of heroin. It only fights the effects

It's not our place to judge these people for what they have done to themselves, but we're not God either. It's not our job to judge people- it's our job to save lives.

I'm not judging them. I'm rationing my resources to do the greatest good for the greatest number of people.

we responded to the projects on School Street several times on one shift for the same thing.

If you save enough of them, they know that its ok to keep taking this s***. "Give a man a fish and feed him for a day, teach a man to fish and you feed him for a lifetime.

And the correct way to titrate Narcan is enough so they can walk to the bus......

I watched medics do this, including walking them down 5 flights while carrying their own IV. I have also seen medics get the s*** kicked out of them after thinking that this was a good idea.

[Goose 188]

If a patient is in asystole and given IV Narcan with good CPR, then their chances of survival increase greatly.

IV Narcan is different then nasal narcan. It absorbs in a much different way, and has been proven to save lives without significant side effects.

Regardless, there is bad heroin going around, and every tool should be used to combat this. It's not our place to judge these people for what they have done to themselves, but we're not God either. It's not our job to judge people- it's our job to save lives. And this will give the patient that extra edge where time is critical, so why isn't this being done?

People who have gone through these bad heroin going around situations know....that you sometimes even run out of Narcan because there are so many....I remember this situation happening in Yonkers when I was an EMT.....we responded to the projects on School Street several times on one shift for the same thing.

And the correct way to titrate Narcan is enough so they can walk to the bus......

I don't want to get into a debate about narcan or how it's absorbed, but i did do a quick search before my original post to see if i could find the absorbtion rate of IN narcan specifically and found this:

Fortunately, naloxone is a small molecule that easily crosses the nasal mucosal membranes. After intranasal (IN) administration, naloxone exhibits opiate antagonist effects almost as rapidly as the IV route with bioavailability approaching 100%.

Source

Additionally, i would rather see public funds directed to programs like DARE to target local youth and prevent future use of this crap. I just don't see the point of spending money in rolling out a program that expands the availability of naloxone in order to try and save people who very well may go back to cooking up some black tar the second they are discharged.

That said, i respect where you're coming from and the study was an interesting read

Edited March 29, 2011 by Goose

[Ga-Lin 86]

Our BLS 1st Responders are trained and equipped with Epi pens to help patients in anaphylaxis and albuterol to treat asthma. Anyone suffering from anaphylaxis or asthma generally has little or no control over these medical conditions.

While this may sound a little cold, but at what point do we stop taking responsability for the stupidity of others? You play russian roulet with heroin and you may take a bullet. Why is it our responsibility to protect you from yourself?

I have no problem with ALS units providing this service, but we have limited resources and its getting to the point that if we add something new, we need to take something away.

Now, now, Barry, you can't use this argument. The FD has been taking responsibility for other peoples stupidity for the past 200 yrs!

[comical115 32]

Why not give PD another avenue for criticism from the non under-educated public? Let PD do their job so the scene is safe when the medics get there and let them deal with the medicine.

As for BLS, I still don't know why NYS hasn't given the combitube / king to BLS minus the EtCO2 requirement. Its a great tool in the hands of a properly trained provider, and in my opinion more benefit then naloxone in this situation (but that's another discussion / thread...).

Bump to BLS getting out the door in a timely fashion. Should It is a higher priority then IN naloxone.

Edited March 29, 2011 by comical115

[Just a guy 493]

I have ZERO sympathy for people who put drugs into their bodies. They know the risk... if you get a hot bag and thats the end of the line for you, tough s***.. you did it to yourself.

I would much rather see the time of EMS spent helping the victims of Emergencies who didn't cause the situation themselves.

Just my opinion

[FDNY 10-75 640]

There is a BLS narcan pilot in progress here and it's working out so well that it is likely here to stay.

[ny10570 745]

First and foremost, it is not a bad batch of heroin going around, but an extremely good batch cooked with synthetic opioids, most commonly phentanyl. Narcan is absolutely dangerous in the wrong hands. The jackass medic that uses it just to ruin the high or deliver a vomiting patient to the ER is even more dangerous than the EMT who dumps 2mg into the junkie who's just nodding out. Narcan is not there to assist in obtaining a patient history, it is used to restore respiratory effort. So now this BLS crew is doing a phenomenal job of ventilations. One member has the seal and the other is providing ventilations. After administering 2mg of Narcan IN the patient, before becoming fully awake begins vomiting. These two EMTs, used to this pt not being exactly compliant with ventilations since he's not dead, just doped up to the gills; continue ventilations until they've filled his lungs with stomach contents. Eliminate the narcan and this is a scene I've witnessed a couple of times. These patients need quality ventilations by competent rescuers.

More often than not good CPR alone is enough to get back opioid arrest because that main affect is respiratory. Correcting the hypoxia and hypercarbia is what revives your asystolic opioid arrest.

IN, IV, and IM narcan are the same drug. IN and IV systemic distribution rates are similar in the lab. However apnea, nasal congestion, and structural damage to the turbinates all result in decreased absorption during nasal administration. Nasal administration works great with someone with clear sinuses that can inhale for you. Apneic junkie who's probably snorted more things than you care to think about therefore isn't going to absorb so much. My preference is IV, IM, then IN.

A more pressing topic in my world is the need to transport opioid over doses. There was a study out of San Diego in the 90's and another from the midwest more recently where zero patients treated by EMS with narcan for opioid overdose were found to have died in the ensuing 12 hours. While the emergence of synthetic opioids may impact this, as of now no one can demonstrate harm in offering overdose patients an option to RMA.

[Bnechis 3,961]

Now, now, Barry, you can't use this argument. The FD has been taking responsibility for other peoples stupidity for the past 200 yrs!

In our case, its only 150 years. The problem now is we have the highest demaned in our history and the fewest resources. While we will continue taking responsibility for other peoples stupidity we have reached the ceiling.

[antiquefirelt 994]

While the emergence of synthetic opioids may impact this, as of now no one can demonstrate harm in offering overdose patients an option to RMA.

How are you going to RMA someone who's immediate history includes opiate drug use? Would that not call into question their ability to make sound rational decisions about ones own health? I understand the reality of the situation and the hospital is going to push them out on arrival, but I'd think this would significantly stretch your neck out? I'd say there's a 99% chance that anyone revived by Narcan is going to refuse to want to spend anymore time with you than required, we know this to be true through years of experience. While I tend to agree that we are part of the problem by enabling users by bringing them back over and over, I'm not in favor of treating them and then letting them wander back off unattended just to boot up again.

[FFLieu 70]

I have no sympathy for people who knowingly poison their bodies, but all feelings aside, I would never RMA an overdose patient. Even if Narcan was pushed (slowly, I hope, otherwise that's a real mess), I would still take the patient to the ER. Whatever the hospital does with them after I bring them in is on the hospital, but at least they got the opportunity to detox a little and maybe even get clean.

[ckroll 101]

I would much rather see the time of EMS spent helping the victims of Emergencies who didn't cause the situation themselves.

Then we don't help drunks, or fat people, or people who don't exercise, or who people drive on bald tires or text or pretty much ANYTHING that happens to a teenager. I guess we just deliver babies.... No wait, they did that to themselves, too.

[ONEEYEDMIC 68]

If a patient is in asystole and given IV Narcan with good CPR, then their chances of survival increase greatly.

IV Narcan is different then nasal narcan. It absorbs in a much different way, and has been proven to save lives without significant side effects.

Regardless, there is bad heroin going around, and every tool should be used to combat this. It's not our place to judge these people for what they have done to themselves, but we're not God either. It's not our job to judge people- it's our job to save lives. And this will give the patient that extra edge where time is critical, so why isn't this being done?

People who have gone through these bad heroin going around situations know....that you sometimes even run out of Narcan because there are so many....I remember this situation happening in Yonkers when I was an EMT.....we responded to the projects on School Street several times on one shift for the same thing.

And the correct way to titrate Narcan is enough so they can walk to the bus......

Or if the ER staff is really mean push it fast as your backing inti the bay so the pt showers the staff with puke! Well that's what I heard anyway!

[ckroll 101]

How are you going to RMA someone who's immediate history includes opiate drug use? Would that not call into question their ability to make sound rational decisions about ones own health? I understand the reality of the situation and the hospital is going to push them out on arrival, but I'd think this would significantly stretch your neck out? I'd say there's a 99% chance that anyone revived by Narcan is going to refuse to want to spend anymore time with you than required, we know this to be true through years of experience. While I tend to agree that we are part of the problem by enabling users by bringing them back over and over, I'm not in favor of treating them and then letting them wander back off unattended just to boot up again.

By that argument, we can't RMA anyone eating a Big Mac. Letting someone die solves our problems, it does not solve the patient's problems. EMS absolutely must leave their personal prejudices at the station door. Our job is to improve outcomes, not to pass judgement. That's a different job that pays much more.

As it was described to me many years ago, anyone who has overdosed and has regained consciousness prior to intervention is a candidate for refusal if they so desire. Anyone who has had interventions needs to be seen in an ED. Are we not supposed to titrate the patient back to breathing and airway patency without making them mean and ugly?

[JohnnyOV 2]

As much as the general population aggravates me, and while I have zero sympathy for people who bring harm to themselves, we still, regardless of law, have a sworn duty that we signed up for to help people, regardless of the cause. Nothing would ever make me turn my back on someone who needs help; its what we signed up to do, and if you don't like it anymore, there is the door.

[antiquefirelt 994]

By that argument, we can't RMA anyone eating a Big Mac.

My comment wasn't based on their attempt to do harm to themselves, but in reference to their impaired ability to make sound decisions? Are they properly A&O x?

Letting someone die solves our problems, it does not solve the patient's problems. EMS absolutely must leave their personal prejudices at the station door. Our job is to improve outcomes, not to pass judgement. That's a different job that pays much more.

This I agree with 100%. We're still the one group that generally has not been accused of treating any person(s) any differently based on any discriminatory factors. And since we agree letting them die is not a real option, we need to find options that correct the issue before it becomes an issue. I'll need a few more bucks in my paycheck to figure that piece out. Edited March 29, 2011 by antiquefirelt

[ny10570 745]

I love all this hate on the idiots who's own actions bring us to their door. People who drive to fast, don't buckle up, or drive under the influence all get our care. People getting lost on mountains, getting into fights, and all sorts of other stupid actions get an eager response from us. Heart disease is the biggest preventable killer in emergency services. Look around and see all the members who are a bit more than an ideal weight. Should they all go piss off because of their affinity for fried food and cold beer? Yeah, the regular abuse of the system caused by heroin addicts, alcoholics, meth addicts, etc is frustrating. However WE CAUSE THE ABUSE. The intox sleeping on the corner usually doesn't want to go to the ER. The junkie who has nodded out didn't intend to end up in the ER and unless they're not breathing do not need the ER. Data analyses from two different systems shows that after administering narcan these patients just go back to doing what they were doing. Taking them to the ER ends up with the same result. There's not an addict alive that doesn't know where they can get help. Dragging them to the ER isn't going to change their behavior and if they're alert and oriented taking them to the ER can be construed as kidnapping.

[ONEEYEDMIC 68]

How many times has anyone RMA'd a diabetic after given Insta glucose, glucagon or even D50? BITD(back in the day) that happened all the time. Sometimes after the patient was semi-conscience or even unconscience. As much as we tried to convince them, they refused. Call Medical control advise them and be on our way. It is the same scenario here. You give them the cocktail, they wake up and are pissed cause you took their high and refuse to go. Of course you know you will be back there soon, same with the diabetic!

[ckroll 101]

How many times has anyone RMA'd a diabetic after given Insta glucose, glucagon or even D50? BITD(back in the day) that happened all the time. Sometimes after the patient was semi-conscience or even unconscience. As much as we tried to convince them, they refused. Call Medical control advise them and be on our way. It is the same scenario here. You give them the cocktail, they wake up and are pissed cause you took their high and refuse to go. Of course you know you will be back there soon, same with the diabetic!

My understanding, and someone please correct me if I'm wrong, is that narcan is relatively short acting with respect to some narcotics, the effect being that narcan can wear off and leave the patient yet again in need of resuscutation. If a pt wakes on his own, then the high may be manageable without intervention.

It is much the same with diabetics in that those taking insulin with low blood sugart can be turned around with D50 and let go in some circumstances, but those taking oral medications have to be transported because oral meds have longer action and will drive the blood sugar down again.

[ny10570 745]

While narcan does have a short half life it remains therapeutic long enough to get the patient past the respiratory depression. Prehosp Emerg Care. 1999 Jul-Sep;3(3):183-6 is the San Diego study where 317 patients RMAed after receiving narcan and none were found to have died of overdose over the next 12 hours.

A greater risk to diabetics is long lasting Insulins like Lantus with its 18 hour effective coverage. They still however do not require ER transport just because they're taking Lantus. Now if its an accidental overdose then they would need the increased monitoring available in hospital. Otherwise if its the usual they skipped dinner before bed or just haven't been eating as much as normal you treat them the same. Suggest they be evaluated at the ER, eat a complete meal, and contact medical control if that's your protocol before accepting the RMA.