Narcan: The Band-aid No One Knows How To Use. By Anna Ryan ,NREMTP
We’ve all had that call come across from dispatch that you know from the start is an overdose. “Man in car in abandoned parking lot, unresponsive and possibly not breathing.” The opioid crisis being what it is, the likelihood that we will be responding to a patient who has had just this side of too much is more likely than not. We go screaming down the boulevard, lights and sirens, and dispatch comes back and tells us that one Narcan has been deployed. Great! We have a 3-minute ETA and since someone is on scene with the patient surely their airway is being well managed so when we arrive we should be able to assess someone who is either awake or heading in that direction. 1 minute later, your BLS arrives on location. Perfect! More skilled providers who will not only know how to stimulate a respiratory drive but also look for signs of consciousness. Dispatch keys you up again and you wait for the news that your patient has started breathing better or is conscious but instead you are informed of another Narcan deployment. Wait, what? Why? Your foot gets heavier on the gas pedal, thinking that maybe something has gone horribly wrong with this patient. Dispatch keys you up again, a third deployment. WAIT! STOP GIVING THE DRUG! You arrive on scene, march up with all your equipment and the crews present you with 3 empty vials of Narcan given intra nasally, a proud look on their face, as they all stand around the patient still breathing at 4 times a minute with no oxygen on their face and not a single BVM in use. When you ask why these measures haven’t been taken, the answer you get is that they have been waiting for the drug to work and when it didn’t work immediately they just gave more of it and continued to wait.
Anyone else ever come across this scene? Anyone else’s blood pressure climb just a little higher? That weird eye twitch thing start up again? Yeah, we get it. The problem is that if you answered yes to any of those questions then its not because the situation happens, its because we haven’t done enough to make sure it doesn’t happen. Narcan isn’t a miracle cure and we aren’t telling our providers how to use it correctly.
Watching the seven-minute instructional video released by Narcan on how to use its product, I noticed some things. 1) this is clearly made for the general public who aren’t supposed to know the ins and outs of patient management. 2) There’s nothing covered about respirations or breathing. 3)No one actually knows what pin point pupils are once they walk away from the video. 4) Different routes a patient can take the drug aren’t discussed and further how those routes would affect the way the Narcan works on a patient.
So why is it that this short training video is acceptable to train first responders as well? Other videos across various channels after a simple YouTube search spend more time on the equipment than they do on the action of the drug, the possible side effects of the drug (no matter how small the percentage is of having a seizure or something more dire post admin), how to manage an airway and why we don’t necessarily need to wake these patients up all the way. In the heat of the moment with a person turning an unnatural grey color in front of you, their breathing too short and their family members begging you to help them the adrenaline flows, and time goes slower but what about understanding what we are doing to the public we serve instead of giving into sheer panic?
When I started as an EMT, the only thing we could do for an overdose was bag them until their respiratory drive kicked back up again. In the calamity of the public outcry the deployment of Narcan into hands other than trained professionals has seen its positive outcomes, no doubt, but then we have more scenes like this one than we don’t. So, if we are going to deploy this intervention, what kind of best practices can we reasonably expect from providers of all levels and how do we train them so they aren’t dumping their monthly supply of Narcan into a single overdose patient?
Police, Fire, BLS have all been given generalized training for the use of this drug. Key words like “unresponsive” “slow breathing” and “overdose” are what should clue the provider in to the possible use of Narcan after the training is over, but lots of other drugs can cause those symptoms in an overdose as well. Is Narcan considered a dangerous drug? Overall, no. The FDA finds that about 1.3% of patients who received Narcan to reverse an overdose suffered from its more serious side effects like seizures and pulmonary edema, but that was a small population sample of only about 450 patients. A study conducted out of St. Mary’s hospital in CT affirms that the actual instance of serious side effects like pulmonary edema occurs anywhere between 0.2% and 3.6% of the time in reversing an overdose in both the prehospital and hospital settings. So, giving Narcan in a suspected opiate overdose is probably considered a good measure especially if those symptoms are present. But then what? The training video doesn’t tell us what to do other than wait and call 911. We are 911!
Let’s also talk about the act of overdosing the overdose. More of a good thing isn’t necessarily a good thing! Look at that hypothetical call above. For a 3-minute response, this patient got 3 full vials of Narcan making the full dose 12mg prior to ALS contact. The British National Formulary suggests that patients receive does of 0.2mg-2mg boluses that will take up to 3.4 minutes to take effect depending on the route of administration, IM being the slowest, IV being the fastest, and IN being somewhere in between. A second dose shouldn’t be given for 5 minutes from first administration. Check that timing again. One dose of IN Narcan can take up to 3.4 minutes if not more depending on how much drug the patient took and then how they took it. If your patient snorted their dose, you’re looking at longer. In a 3-minute response, this patient received not only the max suggested dose but over it! Why am I freaking out about this? Crash course in opiate addicted patients: patients experience a hefty dump of catecholamines (the same class of hormone as epinephrine) when given large doses of Narcan, which causes vasoconstriction. That constriction causes a reverse or a decrease in blood flow in the pulmonary vasculature which leads to fluid buildup. This pulmonary edema means that while the patient isn’t high anymore, now they’re drowning. Now lets mention how negative pressure pulmonary edema is also a consideration. The way Sam Ireland describes it in his article “Stop Using Naloxone” is “….For a little experiment, completely block your nose and close your mouth, and then try to take a gentle breath in. Uncomfortable? It's a very weird feeling. Now imagine that your patient doesn't have conscious airway control of their upper airway, and then take a large forceful breath in while their airway is closed. This causes a negative pressure in the lungs that draws fluid in. This is the result of not managing an airway prior to giving naloxone, and it could kill your patient. “
The summary of all this medical jargon? AIRWAY IS MORE IMPORTANT THAN DRUG!
The initial training in providers is lacking to say the least. Adult learners retain knowledge best when they can see what they are looking for, touch what they need to work with, and understand what their purpose is after initiating an action. We leave our providers high and dry, twiddling our thumbs on scenes waiting for the drug to stop the scary thing happening to the patient. Incorporating visual aids into the training i.e.: pictures of pin point and non-reactive pupils, videos of normal and abnormal respirations, step by step guides of how to properly bag a patient or the use of HFNC, labs that offer practice time and scenario training after the lecture and, dare I say it, yearly department competencies. Let’s take it a step further and provide airway management training as well. Proper airway positioning, the use of a BVM, even the presence of a respiratory drive and why it gets suppressed with opiate use are vital to the successful use of this intervention. Too much for one sitting? I don’t think so. These are core concepts and are by no means too advanced a topic to educate providers on. Even if we don’t teach an in-depth lesson on the mechanism of the drug, we are asking either non-medical providers who carry medical equipment or lower level providers to administer a life saving antidote, they should at least know how it works and how to help it along.
Now we can continue to pontificate about how we aren’t trained well, we panic in situations with high emotional buy in, we don’t treat our police or firemen as if they need to know what they’re doing as long as they go through the motions but what does that actually change? Not much.
Let’s face something together. WE ARE BAD AT EDUCATION. After an initial certification of any kind, whether it be your first EMT class or any one of your elective courses thereafter, or even the department in-service on literally anything we do the bare minimum. We throw the information at you at some god-awful hour, hope it manages to bounce off your face and onto a multiple choice test, watch you play with some cheap model of the real thing and send you on your way. What’s worse? We hold you accountable for that information until the end of your professional life. One class. That’s insane and incredibly dangerous. There’s no practice, reassessment on the educator’s side, reassessment of competency. If you took your Narcan training a year ago and managed to go a whole year without seeing one over dose, then one fateful day you walk in to an opiate overdose and it’s absolute chaos. Now what? Family is screaming and begging for you not to let their loved one die, the patient is doing their very best to sprint towards the light, you have no medics available, you don’t know what else this patient took and suddenly you remember you took this one class this one time! Was it one dose every five minutes? Or five doses in one minute? More is better right? And away we go…
The education system we have now is outdated and money driven and frankly putting both provider and patient at risk. That’s not just EMS, that’s all responders. We have come to adopt a pay for pass mentality in our joint cultures. Someone put money on the line for this class, whether a department or a training fund or our own pocket, and that means that no matter how we participate at some point someone is going to give us a certification. Our standards have faltered, we don’t strive for excellence and in this case most days we barely hit competence. The onus falls on the educators and those who fund our budgets. You can’t have an education department that isn’t allowed to offer more than the same classes over and over again and expect to have competent and confident providers. Variety, reassessment on standing skills, evidence based lessons that branch out from what has become a traditional classroom is a standard to meet but lets also talk about full time staffed education centers that employees are required to meet monthly hours for, in any responder department, to ensure that we are not only meeting the standard practice but exceeding it.
When Narcan was given to other providers, it was done so as a response to a problem that would lose elections otherwise and the general public had no idea that the people providing the antidote wouldn’t know what to do next. The fact that studies have shown a decrease in overdose deaths since the drug was rolled out, a 9-11% reduction according to a 2017 study conducted by the National Bureau of Economic Research, is fantastic but how many of those studies include the need for ALS intervention after the Narcan administration, the need for more than one dose and how long it was between doses, and then those who did have adverse reactions to the use of the medications in high doses? Almost none. You must learn to walk before you can run and giving this antidote out to undertrained providers is unfair to them and dangerous for all involved. When the only answer we have given our providers is to give more drugs, we must take a look at ourselves as educators and think about who we are actually selling short. Does that mean drastic education reform? Yeah. I think it does. And I think it’s a conversation we should all participate in as actively as possible on all levels. After all, we shouldn’t have to subject a defenseless overdose to our ineptitude.