Tuesday, April 10, 2007

Fun With Narcan

On the overnight shifts I often get called to the CCU for codes and such. One night recently I was forewarned by the respiratory tech that an overdose patient was in respiratory failure in the CCU and would probably need to be intubated.

The critical care attending was in Russia on a trip and had asked one of his internal medicine buddies to cover for him and the coverage doctor had no interest, and, quite frankly, no business, taking care of this patient.

I arrived at the bedside to find a disheveled middle-aged man quite incoherent and with oxygen readings which were indicative of respiratory failure.

Me (to the nurses): "So what did this guy overdose on and who called EMS?"

Nurses: "Methadone; He was 'found down' in the shelter."

"Found down" means just what it sounds like, some schmo is found on the ground and when the paramedics arrive everyone already present gives the old 'Italian Salute" (shoulder shrug).

One thing about methadone is that it lasts a hell of a long time (at least 24 hours), and, without getting into pharmacokinetics and discussions of drug half-lives it is enough to simply realize that it's basically liquid heroin and is prescribed both for chronic pain and for heroin addiction.

Since it lasts so long it is possible to reverse its effects either in the field or in the ED with a drug called "Narcan" AND have the narcan wear-off while the methadone takes the patient to respiratory failure and la-la land again.

Narcan is a pure opiate antagonist. In other words it completely counteracts all the effect of opiates in the human body. Opiates cause euphoria, respiratory depression, coma, and, as an end result, death in overdose. Narcan, given in the appropriate setting, is like an 'on switch' in the patient.

Usually, since those given narcan are in the habit of using opiates, the effect of narcan is not appreciated. In a word, you have just stomped on a huge buzz (never mind that the patient was 'walking towards the light' when given the narcan). I have had some of my medics beaten-up by patients saved from the brink of death by narcan as it does precipitate ACUTE OPIATE WITHDRAWAL (which is a lot like the wicked witch touching you with a wand and giving you the worst case of the flu ever recorded).

So, long story short, the patient in the CCU did wake up with narcan and the nurses thought I was a genius for about 5 minutes. Then we noticed he wasn't moving his arms and had no purposeful response to painful stimuli in the upper extremities. Question; At 3am, with this patient flailing about in acute withdrawal and possibly paraplegic, what do you do? The answer is not, "call the internist".

This patient became mine for the next two hours as I intubated him, put him in a cervical collar, put him on a propofol drip for sedation, and did CT scans through his C and T spines. I was concerned that when he was 'found down' that he may have taken an unwitnessed dive off the top bunk at the shelter. His scans were pristine and he eventually started moving his arms. I have no idea why he didn't move them to begin with and I no longer care.


  1. I am in awe that you are able to undergo this kind of stuff day after day and not completely burn out.

    Your last line cracked me up!

  2. I am 95% burned out. I've got at least three or four shifts left in me. The burnout factor is like driving your car on empty. Hopefully a gas-station appears (vacation), if not, well, there you are somehwere in the jungle. Radiocative girl, thank you for your kinds comments and please do continue. Glad you are doing well.

  3. Just found you today, have read everything cover to cover and you're seriously making me reconsider re-entry into EMS.

    I'm thinking homelessness under the nearest freeway overpass is a better alternative. Now where did I put that case of Jack Daniels quarts?

  4. thanks ed, agree on the overpass alternative. i want to, as one of the local paper letter-writers suggested recently, become an illegal alien retroactively. i would have more benefits and pay less taxes.

  5. Seems as if big business is winning this war. When I left EMS back in '89 they started bonusing medics for runs, the more you runs you completed the higher the bonus.

    Which lead to the scoop and drop mentality. The unions just couldn't get their mind around the fact that if they were paying bonuses for every run they could afford to pay a decent wage. Here in CA a private company medic makes about $15 an hour while a EMT makes $10.

    Naturally if it's a uninsured ride to the ED there's no bonus. What happened to quality of care vs. numbers? Some thing just are meant to be run as a big business.

    As my luck would have it I have to do a year as an EMT because I let my medic license lapse. Maybe a year shuffling pt.'s will cure my current burn out.

  6. Great post, you crack me up. I am stuck on one small detail, what kind of idiot hospital administration allows the intensivist to leave the country without suitable coverage? Oh wait, do you work at my hospital by any chance?

  7. Ed, as a former EMS director I feel your pain.

    ERNursey, perhaps we do work in the same hospital. In all honesty though, we have had only one intensivist for four years and we may lose this one. No one believes me when I warn about the specialist shortage but it's already here.

  8. Well I dont see why "Methadon" is liquid heroin.
    I didnt get high, I did not enjoy it at all when I had to consume it. So either you are trying to say "it helps ease the pain and does not create dependency or hallucinogen reaction" or you seem to have no idea what you are talking about. I mean I like your texts but this is ridiculous. I hate it when people make every pain patient who has to take it feel like a fucking junkie. Damn it! By saying that you even contribute to that prejudice.

    Nonetheless I love your blog and admire your work.

  9. Ben,
    If you took it for pain and no longer take it then great. It is, in fact, so similar to heroin both chemically and in the body that their molecular structures are almost identical. You are correct in that, since it lasts so long it does not produce the immediate high of heroin, however, if you are on it long term and try to stop you will withdraw. Them's the facts.

  10. Dude,

    Narcan drip! Especially for long acting or massive overdose of narcotics. We have a standing protocol in our ED for the administration of Narcan. 5 points restraints first, Foley in first, then the narcan. Could this ol' coot have a central cord syndrome? Aaah, who gives a hoot.

    Your EM Colleague.

  11. no central cord though certainly a consideration i entertained... when he got to the scanner a little underdosed on propofol the hands they were a flailin'.

  12. Too bad nights in the ED can't be more like a marathon of Love American Style. Wasn't that a great show. Anywho, I digress. Narcan drips work great. I love "found down"and hope to be "found down" some day.

  13. shrodingers cat...I don't quite remember LAS, but remember the music and that was FUN! Now I digress...I also hope to be "found down" but I have a DNR/advanced directive in place. Hope you do also--unless you want us adrenaline junkies to be pumping and cutting up on your chest! No thanks...I have been lurking, and you just crack me up!

  14. schrodinger's cat is perhaps the funniest human currently alive. perhaps, dear cat, you will grace us with one of your classic haikus?

  15. Anonymous posted "5 points restraints first, Foley in first, then the narcan."
    Would you please tell me what the fifth point is? We routinely use, of course, four point restraints. Never heard of a fifth point.
    ER RN

  16. If you think shrodingers cat is funny here in cyberspace, you should spend time with him on the golf course, bowling alley, casino, racetrack, and/or family gatherings. It is a never ending riot of silliness. But I digress...

    Your's truly,
    shrodingers gerbil

  17. i have done these things with 'the cat' therefore i do know of what you speak, anonymous, but i don't think i would want to be his gerbil.

  18. i've never hear of a ''fifth point'' in the restraints but i assume it would be the head... perhaps a c-collar and some tape to the bed.

  19. Ouch. Nonetheless, would love to try it out sometime...
    Hey, shrodingers gerbil, I have no doubt that cat is hilarious, and gives much enjoyment to those around him (probably knowingly and unknowingly, right?) My appy is still intact, but for how long, I just don't know...
    some witty er rn name I have yet to come up with...

  20. You suck. Nurses seem to get enjoyment out of the pain that people go through when given narcan for overdose. I was given it last afternoon after a friend of mine(paraplegic) could not wake me up or get me out of his car,which I walked to. I was given 0.4 mg of narcan. I woke up and answered the questions(correctly) that were given to me by the paramedics. The er doctor was called bc/ I refused treatment,and asked to be released. My vital signs were fine. As I was literally going into to the e/r room, the Ambulance service,whom was mildly mad because I was pissed, decided to give me 2.0 more mg of narcan. I seriously believed she did this purposely to get her rocks off. When I got into the ER room, everyone seemed so happy and sarcastically delighted to see me lose
    motor function and the obvious pain i was in. They were being so sarcastic with me that if I had my wits about me, I would have been arrested for punching out the fat,bald fuck that I am referring to! I know why you sick wannabe doctors get nursing degrees, you are power hungry,too poor, too stupid,problem HAVING/DIVORCED/ and do not have a life so you put/bring your personal shit to work. and EMS workers are even lower/mu than nurses.so take what i said and multiply it by 2 and you get the 2nd most worthless medical professional

  21. anonymous, you are clearly in need of the kind of help that doctors, nurses, and paramedics can not give. so i will pray for you. i will also tell you that your little post here has reminded me of why i had to leave the ER, because if i didn't leave I would have ended up (with someone like you), NOT giving that second dose of narcan, and you would have died. and no one would have known. so sell crazy-pitiful somewhere else.