"That Narcan Shit"

What follows first is fiction:

“482. Lawrence Street. 2nd Floor, unknown on a one. PD on the way. Advise when you get there.”

We were around the corner having just cleared Hartford Hospital. “Shouldn’t we wait for the cops?” I said, as Troy grabbed his house bag and monitor from the side door.

“No, it’s shift change. We’ll be out of here before they even get here. Besides it’s just going to be an OD. This place is the junkie’s version of Studio 54. They buy their heroin down the street, and then head for their club. They ought to install an emergency syringe of narcan behind glass on the wall up in the shooting gallery. Then when one of them stops breathing, his homeys can break the glass, pull out the syringe and zap them with the narcan without having to bother us.”

Narcan was to heroin what kryptonite was to Superman. It worked by reversing the effects of the opiate on the brain. Once injected in the body, it raced up to the brain, kicked down the party door, slapped the brain hard and said “Wake the fuck up! The shindig’s over!” Within moments of getting injected with narcan a previously stuporous junky was on his knees puking, his high gone, his mind a stoned out Daffy Duck “Who? What? When? Where? Why?” routine until he finally recognized a paramedic standing over him, and realized he’d gotten “that narcan shit.”

A skinny woman who looked like she hadn’t bathed for days met us out in front of the abandoned partially burned out building and led us up the staircase to the second floor, then down a hallway to a room without a door. I carried a flashlight with the plastic IV bag wrapper over the light creating a makeshift torch. We saw a man laying against a wall, a belt around his left bicep. The syringe lay on the floor just beyond his fingers. Troy leaned down and felt the man’s neck. From where I stood I could he was still breathing, but only a few times a minute.

“How well do you like this guy?” Troy asked the woman who’d led us to him.

“I like him better now he paid me the money he owe me.”

The unconscious man’s wallet protruded from his pants. A roll of bills stuck out of the woman’s shirt pocket.

“Pretend he’s dead. Okay?”

“He’s dead?”

“No, no, he’s not. We’re going to save him. I just want you to pretend that he’s dead when he comes around. Can you do that?”

“I think I got you,” the woman said. “You giving him that narcan shit?”

Troy took the prefilled syringe out of his pocket.

“This going be good,” the woman said.

Troy wiped a spot on the man’s shoulder with an alcohol prep, then stuck in the syringe and pushed the drug.

“What’s his name?” Troy asked, as he discarded the syringe in the sharps container in the bag.

“Samuel.”

“Lee, grab the tarp over there.”

I could see the man was beginning to breathe better, rousing.

I handed the tarp to Troy. Troy leaned down and whispered in the man’s ear. “Next stop. Pearly Gates. Pearly Gates. Next.”

Troy spread the tarp out next to the man whose eyes were now open though he looked groggy and diaphoretic. He sat up suddenly, fighting back a retch. I thought he might throw up.

“It’s a shame we didn’t get here in time,” Troy said. “I hate to see a life end like this. You have anything you want to say about your friend?”

“That motherfucker owed me money, but I still tried to save his life.”

“You almost did, but we were late I’m afraid. Here lies…What did you say his name was again?”

“Samuel. Samuel Pugh.”

“Here lies Samuel Pugh. Ashes to ashes, dust to dust. Another one’s gone, another one’s gone…” He looked to me.

“Another one bites the dust,” I said.

“That’s what he gets for not listening to his Mama. Let’s go eat. I could go for tacos.”

“Hey,” the man on the ground said.

“You hear anything?” Troy asked.

“No,” I said. “But I don’t hear so well.”

“I don’t hear nothing,” the friend said.

“I thought I heard something.”

“Hey!” The man grabbed Troy’s leg. “I know you. You the one always giving me that narcan shit, motherfucker.”

Troy started shaking in mock fear. “Do you guys see anything?”

“No, I don’t see anything,” I said.

“Me neither.”

“Something’s touching my leg. I can’t move it.”

“Quit fucking around. Let’s get out of here.”

“I swear something’s got my leg.”

“I got your leg motherfucker. I ain’t dead.”

“Your imagination again,” I said. I lifted the tarp up, and pointed at the floor. “See. Dead is dead. Cut it with your seeing ghosts again.”

The man let go of Troy’s leg. “I ain’t dead.” He touched his chest and face. He looked alarmed. “What’s that shit?”

“Oh, dear!” Troy stared in mock horror at the apparition. “I’m not well.” He grabbed the medic bag and walked toward the stairway, shaking his head.

“He’s been seeing ghosts all weekend,” I said to the woman, as we started to walk away.

“He must work too hard.”

“Wait! I ain’t dead!” The man called after us as he tried, stumblingly, to get to his feet. “I ain’t dead!”

– excerpt from Mortal Men

***

Above is an excerpt from the EMS novel I have been reworking on for the last many years. It seems every EMS novel or movie has an obligatory wake the junkie up with narcan chapter and I, as evidenced above, am as guilty as the rest.

What follows now is true:

When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie’s IV, and slamming the narcan as they’d go through the ED door so the junkie would sit up and puke all over the medic’s nemesis — the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.

I did, however, slam narcan into lots of junkies and wake them up. When I say slam, I’m not taking about pushing the narcan in like I push adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.

I’d slam it. They’d puke, curse, rip their IV out and stalk off. One guy I found in an abanoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push narcan. I’d had no idea.

Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.

Slamming a full dose of narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.

It used to be if I was called for an OD and the patient had used heroin, they got narcan even if the
y
were breathing okay. As long as they were slightly altered, I’d hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.

“Did you do drugs?”

“No.”

“Then why do you keep dropping asleep?”

“I didn’t do drugs.”

I’d push the narcan. They are wide awake and puking. Stupid. Them and me.

“Did you do drugs?”

“No.”

“Then why are you wide awake now and puking?”

I don’t give narcan now as much as I used too because I don’t work in the city nearly as much, plus now, like I said, I only give narcan if I suspect an opiate overdose and the patient’s respirations are extremely depressed. Sometimes I bring heroin users in to the hospital and the first thing the hospital staff does is give the patient narcan. Wake them up and make them puke. I shake my head. That’s just no way to treat people. Put them in a hallway and let them sleep it off — as long as they are breathing okay.

We also used to give narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.

Here’s two cases where I gave narcan to coma of unknown origin with bad consequences.

1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did — living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills — opiates — I zapped him with narcan. So now I went from a patient in a smi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I’d just zapped all the pain medicine he needed to tolerate living into the ether. My bad.

2. Called for a possible stroke, I found an 80-yea-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn’t find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Odd. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.

Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of narcan.

Narcan Solves the Riddle, Part I

More Rogue Medic Narcan Posts

Ambulance Driver Article “Naloxone: The Most Abused Drug in EMS”

I particularly like this quote from a Boston Medic that Ambulance Driver cites in his article:

“Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” – experienced Boston paramedic

Rogue Medic sites an excellent study done years ago in LA.

The empiric use of naloxone in patients with altered mental status: a reappraisal.

The study asked the following questions:

# 1 – Can clinical criteria (RR of 12 or less, pinpoint pupils, and circumstantial evidence of opiate abuse) predict response to naloxone (Narcan) in patients with acute alteration of mental status (AMS)?

# 2 – Can such criteria predict a final diagnosis of opiate overdose as accurately as response to naloxone?

-Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar;20(3):246-52

730 patients with Altered Mental Status received narcan prehospitally from paramedics brought to two LA hospitals over 1 year period

Only 25 patients (3.4%) demonstrated a complete response to narcan

32 (4.4%) manifested a partial or equivocal response.

673 (92%) had no response.

19 of 25 complete narcane responders (76%) were ultimately diagnosed as having overdosed

2 of 26 partial responders (8%) (with known final diagnosis)

4 of 195 non-responders (2%) (with known final diagnosis). Note: They only reviewed 195 of the 673 non responder charts.

Of the 25 complete responders to Narcan

19 had opiate overdose

6 had seizure or closed head injury.

Their conclusion was:

“The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.”

“In addition, response to naloxone created a substantial amount of diagnostic confusion…”
-Ann Emerg Med. 1991 Mar;20(3):246-52

That study came out when I was still as EMT.

Good lessons, as I had learned the hard way.

The bottom line:

Just because they woke up after you gave them narcan doesn’t mean they woke up because you gave them narcan.

15 Comments

  • Ambulance Driver says:

    Good post, Peter.By the way, the medic I quoted in my article now has a blog of his own: Too Old To Work, Too Young To Retire.It’s good stuff.Word verification = “shboolo.”That’s what I usually say when I wake a junkie up with Narcan…right after I don my demon mask and hover menacingly over him. 😉

  • Medix311 says:

    Excellent thoughts to ponder. And I never knew narcan could lead to pulmonary edema.

  • RevMedic says:

    Great info, Peter. I knew about the pulmonary edema, but because my trainee did the same thing.We ended up having to pull over on the way to the hospital and intubating him (the patient, not my partner).Narcan has the potential to exacerbate any underlying respiratory OR cardiac problem.

  • Herbie says:

    Excellent post, Peter. I can say that I have never slammed Narcan in my career, and anytime I hear of a medic doing that, I tend to bitchslap them upside the head. The thing an old wise medic told me to do is that when the syringe is in the IV tubing, flick the plunger-don’t push. They wake up nice and happy. That’s how I give my Narcan, and it works.

  • Kate says:

    Loved the clip from Mortal Men. Thanks for writing!

  • Rogue Medic says:

    Thank you for the links. I like the excerpt from the novel. Having a typical wake up the junkie scene is only a problem if your scene is a typical one. This is not typical. If you do not write something, because it has been done before, you would never write anything. You are adding your own ideas to what has been done before. You are not just rehashing the same old thing.Many people seem to view naloxone as a reboot drug. It is not. Especially for the patient, who is prescribed pain medicine, and has just a bit more than a therapeutic dose on board. So many of us (including doctors) have been taught to use it without consideration of side effects. Naloxone’s side effects are far from harmless.

  • TOTWTYTR says:

    I’ve joked more than once that I’m all for legalizing Heroin, but we should outlaw Narcan. Or maybe I’m not joking. IM Narcan is the way to go, although some people are also using IN Narcan to good effect. Either way the onset is slower than IV, but the side effects are much reduced. Word verification = proloxyWhich sounds like some sort of new drug to me.

  • Anonymous says:

    Fabtastic post, really intersting mate. I definitely had no idea about the pulmonary oedema occuring as a result of Narcan, I have never even seen that listed as an adverse reaction on a protocol. Interesting.

  • seaneddy says:

    Great article. In the system where I work, our protocols still allow Narcan to be used as a diagnostic tool. When I was in my internship, my preceptor always stressed the dangers of “slamming” Narcan, so I never developed the habit of doing it.People seem to think that Narcan is benign and can be given like candy. This obviously proves to be wrong, as it can cause severe withdraws and pulmonary edema. Some systems are even allowing EMT-Basics to administer Narcan pre-loads for suspected narcotic over-doses, or even ALOC. I disagree with this, being that EMT-Basics can manage an opiate OD by artificial ventilation until arrival at the ED or until ALS backup arrives. They cannot however, manage pulmonary edema in the event of an adverse reaction. I think you are right on the money with your treatments. .4mg to start on patients with a compromised respiratory drive is more than enough. And you are definitely correct on leaving them alone if their only symptom is an ALOC, especially if their respirations are within normal limits.Great article. I look forward to reading more as you continue to post.

  • Tom B says:

    “Just because they woke up after you gave them narcan doesn’t mean they woke up because you gave them narcan.”Exactly. I have a good friend (an excellent paramedic) who swears he brought a patient out of asystole with Narcan! I said to him, “If you do a rain dance, and it rains, did the rain dance make it rain?” He didn’t like that! :)Word verification = “pronall”

  • tracy says:

    Excellent. Sooo reminds me of that wonderful scene in “Bringing Out the Dead”…Narcan Resserection. i l o v e that scene. Available on You Tube…i think it’s still there. Thanks so much, Paramedic Peter!

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  • goobrador says:

    Your post has given me a ton of information that I honestly never thought I’d need. That is until I was shot full of Narcan by an unprepared, overzealous pain clinic staff 2 days ago. Had I truly been overdosing I would have been grateful. However, being anxious and overdosing are not the same thing.

    I have a Medtronic pain pump implanted and gets it filled every few months with morphine & Marcaine. I have never used heroin, but supposedly my last urinalysis test from an appointment 6 weeks ago was confirmed as finding morphine. Quite a shock & practically impossible to refute as I’m not allowed to see my medical records.

    So, I’m at my routine clinic visit to have the pump filled (2 days ago) when they tell me this morphine/urine situation & I think maybe the pump is malfunctioning which would be bad. Suggestions of getting a catscan to be sure it’s working properly are thrown around. I’m eager to get that done ASAP as I like living and would like to continue doing so.

    Apparently, it’s not of great concern because after I do another urine test I go to get the pump refilled.

    Afterward, I start to feel a little funny. Probably from being tired, a little anxious about the morphine deal/pump, but totally aware, awake, communicating , just a lil funny feeling.

    The staff freaks out, with the pump nurse who is generally very professional, losing her cool. The one thing she does well, is suggest that they call (I assume) 911, which is ignored until later when they decide I should be kept for observation (close to closing time-unload their radically bad move on someone else). It takes 5 people @ least 7 (before success) tries to insert an iv.

    At some point I’m stuck with what was boastfully described as 2 doses while the whole time I’m thinking the iv is for saline and I’ll be observed in case my heart rate/breathing slows which doesn’t happen. No one tells me what’s going on, what the plan is. Never asked what I had had to eat or prescriptions I had had that day. Had been instructed to take a Percocet before being seen so it would show up in my urine test b/c I was told it hadn’t shown up before. Found out later (but before the melt down) that no, my medicine had been showing up just fine. Another mixed message — with this group over 2.5 years, I’ve come to expect such things.

    Didn’t ever see any doctors enter the room. Just a variety of nurses and techs. No documentation or protocol lists followed in my presence. Stethoscope is only used after several minutes & as a non-chalant suggestion. I swear my friends and I could’ve handled this better!

    They didn’t have the right materials/ ivs/equipment in the pump refill room- had to go to another building entirely. A whole lot of whispering and misleading infirmation. No blood pressure taken. Passed the pupil/follow finger eye test.

    No one lays me on my side – I’m sitting this whole time and then the “2 doses” boastfully injected before kicks in like a bolt of freezing lightening followed by an hour of convulsions, seizures and being wicked cold. I actually didn’t experience an increase in my chronic pain at all. Weird, right?

    I pass out and wake up with the paramedics there, still seizing, convulsing, freezing and no longer sitting up, but now on my back, which I recall asking if I could lie down. In the ambulance they test my blood sugar – 90, A-ok.

    I feel like I’ve been hit by a train when I wake up in ER about 20 minutes later, but otherwise awake and fine. 3-4 hrs later they release me with instructions to rest, continue my meds, Percocet, boluses, etc. and call the ameteur hour clinic on Monday which scares the hell out of me b/c I wasn’t ODing, nor have I any reason for having 3000ng/ml of morphine in my urine 6 weeks prior.

    By far the worst & most frightening (the Narcan part) experience I’ve ever had. Wish someone with your expertise had been there!

  • Mike Jr says:

    Thanks for the post! I have severe/chronic pain from multiple cervical level herniations/osteophytes/DDD/compression/etc. but would also have grand mal seizures and focal point seizures every now and then so I was started on seizure medication. Nevertheless, the seizure medication made my seizures 10 TIMES WORSE! But they wanted me to keep taking the meds, so I stupidly did no matter how many times I told the doctors it was even worse. Anyway, I had a seizure next to my bed and collapsed next to the wood frame and also had a closed head injury knocking me unconscious. They saw my pain meds (police and EMS) and assumed I was in an OD state and decided to NARCAN me! I woke up not only postictal but also in withdrawl and severe pain. They gave me the full dose then treated me as a suicide patient because I have pills for pain and obviously took too much intentionally. What a joke. I know they had the best intentions, but we as a society have gotten into treated everybody as if they are the same and not individualizing their treatment. The best thing is they did not even pay attention to the seizure medication which was RIGHT NEXT TO my pain medicine!! Once they see opiates they automatically jump to conclusions! Oh boy, oh boy!

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