“Did they take anything?”
Sounds like a pretty straightforward question to ask bystanders surrounding your altered, unresponsive or unconscious patient – right?
We often ask this question in hope of being directed toward a clear treatment path – a solution to fix the patient’s “problem.” Regardless of the response we receive, however, we should all begin at the same starting point and end up providing roughly the same level (standard) of care (although this can vary by jurisdiction).
While the scope of practice is a bit more expansive for paramedics than EMTs, there isn’t much more that can be done by paramedics – beyond more advanced airway management procedures – to medically treat many suspected overdose patients, and the integration of opioid overdose kits for all provider levels narrows this gap in scope even further. Because of this narrowed gap, it’s vitally important that EMTs and paramedics think alike when treating suspected overdose patients.
As overdoses increase during the holidays, here are two key tips to help everyone get on the same page with identifying, tracking and treating these patients.
1. DISTINGUISH OVERDOSE, SUBSTANCE ABUSE AND ACCIDENTAL INGESTION
If we count every drug-consumption case that requires a medical response as an overdose, we may not be fully recognizing other types of incidents (or tracking/billing codes and training opportunities).
Some drugs may be consumed accidentally or inadvertently. For instance, you could argue the patient who mistakenly took a double dose of their prescription medication was not a victim of overdose but rather incidental ingestion. The same can be said for the toddler who grabbed a pill on the counter and swallowed it.
Even with substance abuse, the patient’s intent was to take their drug and get some sort of altered status from it – they likely did not intend to harm themselves. “Overdose,” therefore, may best be defined through its intent: to consume (i.e., ingest, inject, inhale, absorb) a substance/drug with the intent to cause personal harm.
Reflecting upon your own past practices or even your agency’s data as a whole, does this mindset change your statistics? For that matter (and not to downplay the reality of overdose situations), does it potentially change everyone’s?
Documenting and tracking from this perspective can help more accurately identify trends within your community. You can then target training toward properly identifying the signs and symptoms of various consumed substances, followed by their appropriate treatment routes. If overdose situations are indeed accurately reflected in your agency’s data, then targeting your training toward opioid response and mental health awareness would be an appropriate route. If your data is altered as a result of this mindset shift, then perhaps a more justified path would be focusing on pediatric “one-pill killer” situations and the adverse reactions to cases like double-dosing beta blockers.
2. CONSIDER WHAT ELSE MIGHT HAVE BEEN TAKEN (OR BE GOING ON)
An opioid alone shouldn’t cause extreme agitation. But an opioid plus something else could…or your patient might not have taken an opioid at all! So don’t start administering 16 mg of naloxone to people on a whim (there are side effects to naloxone, after all). If it doesn’t work the first time, take a step back and think about what else might be going on (and, of course, provide ventilations to your apneic patient).
As a training officer building a monthly CE lecture or even a field training officer working with a new hire, work these scenarios into your repertoire of differential diagnoses. Here’s an example.
Say your patient is a 24-year-old male who was fine all day and later became agitated after friends appeared at his apartment. Now he’s belligerent toward them and “acting strange,” so they call the police…who then request your presence after trying unsuccessfully to calm the patient. As your crews arrive, they find a patient who is ambulatory, sweating, agitated and wants nothing to do with the officers on scene. Discuss what your crews’ initial impressions are. How would they try to calm the patient to perform a thorough assessment?
From here allow your patient to calm down. Say his calmed vital signs are blood pressure 136/76, heart rate 100 and respirations 16. But the patient still says he hasn’t taken anything – now what? Is the patient telling the truth, or is he still altered? Does this sound like an opioid abuse situation? Something else? None of the above? (Don’t forget about diabetes!)
With your next crew tackling this same scenario, build the case in a slightly different direction. Based off recent documentation and tracking within your agency, say you’ve uncovered an uptick in abuse related to substance X. Work in those presentation findings, signs and symptoms, and treatment options. Discuss the possibilities of high-risk refusals and police-only transport.
What might be masking the root cause of this event and the patient’s presentation? Did they take something else? Once you’ve exhausted this scenario, switch groups and start over (with a new cause, of course).
Again, appropriately documenting the “what” in each of these situations can present a dramatically different data result – and that translates to community impact and training needs. What you select as your primary impression and the patient’s chief complaint should be scrutinized on every call – not from a punitive standpoint, but from a data standpoint (which translates to billing, community risk and training standpoints).
Target your agency’s continued education and initial training on what is accurate, allowing for some flexibility to sway the outcome of each scenario based on a few key differences and always keeping in mind what else might be going on.
KEEP THESE POINTS IN MIND
When you’re building scenarios surrounding overdose, accidental/incidental ingestion and substance abuse, keep the following points in mind:
- Is the scenario too complicated? Are there too many variables for the crews to consider and come up with the right differential?
- Does the scenario consider biases? This can be a good thing – and a bad thing too. Our minds are more likely to associate the 24-year-old male with a substance abuse issue than hypoglycemia when he presents with agitation – this is a bias you can capitalize on as a learning lesson. The opposite would be the 64-year-old male with the same symptoms. We’d often start with hypoglycemia before even considering substance abuse.
- Beware of traps. After administering one dose of naloxone for a situation that clearly looks and sounds like an opioid overdose, make sure your crews don’t get caught up with only that treatment plan. Yes, it could have been carfentanil, and yes, the patient might need 20 mg of naloxone to be appropriately treated – but the focus here should be more rapidly directed toward “This didn’t work, now I need to do that!” (and “that” just might be bag-mask ventilations).
- Talk about refusals of care/transport. What if your patient doesn’t want to go to the hospital? They actively tell you that, and it’s recorded on the police officer’s body camera (or even yours) – now what? How should you handle this? Can you release them? What should you document?
Factoring in what else might have been taken might actually include nothing at all. Maybe your first impression is wrong – or not fully right. Maybe there’s something completely different happening to this patient that warrants further investigation and clinical decision-making.
For us to do no harm, we need to properly identify what can potentially cause more harm. If we zero in on identifying what is going on – and what’s been taken (or not) – then we can all do our jobs better (and have the proper data to support us and our training).
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