On May 15, 2019, Appleton Fire Department (AFD) responded with law enforcement and an ambulance to a report of an unconscious patient at a bus station. The patient had not exited the bus when it arrived in the station and bystanders called 911, concerned that he had suffered a seizure. Arriving medical personnel suspected that the male was unconscious due to an overdose of opioids, and administered a dose of naloxone.
The patient quickly awakened and was reported to be confused, paranoid, angry and violent. Law enforcement attempted to get the patient to cooperate with EMS for further assessment and treatment, but he pulled a gun from under his shirt and started firing at responders. One of his shots struck and killed AFD Firefighter Mitchell Lundgaard. The shooter then grabbed a bystander and attempted to use her as a shield, but law enforcement shot him, stopping the assault. He later died in a local hospital.
Single-dose naloxone availability may increase risk of patient agitation
Since the shooting, an attorney that regularly defends law enforcement officers and municipalities in Wisconsin has begun recommending that officers take steps to better protect responders and the patient before naloxone is administered.
In an article published in Police and Security News, Attorney Gegg J. Gunta describes the dangers of the “waking the dragon,” (Read the article here.) These concerns – encountered when an opioid overdose is reversed too quickly – include agitation, vomiting, confusion and combativeness.
This may be more of a concern now that the single-dose nasal spray is commonly available to law enforcement and the general public. Compared to the smaller, titrated doses that EMS providers may give, the 4 mg dose has more potential to affect a sudden reversal of the overdose. Patients may even be angered that their high was ruined. A number of social media videos can be found showing overdose victims going from unconscious to violent within seconds of naloxone administration. While the benefit to the patient still outweighs the risk to responders, those giving the medication must know the risks.
Review law enforcement policies and procedures on patient restraint
In the article, Gunta and his co-author John Peters, Jr., PhD, go on to encourage law enforcement officers to take measures to protect the patient and responders from these reactions by patting them down for weapons and securing their hands with frontal handcuffs or flexible restraints. Frontal restraint, instead of the more common back handcuffing, is recommended so that the patient may be moved into a recovery position.
The authors are quick to point out that these recommendations fall under Wisconsin’s community caretaker functions and they should not be confused with the pat-down and restraint that take place when a person is arrested. Until the medical emergency is managed, patient restraint and pat down is not intended for the purposes of investigation of a crime or to find potential evidence.
Use of restraints to protect a patient from harming themselves or interfering with their care is common in all areas of healthcare, but use in these circumstances is new to many of us in EMS. Take this opportunity to contact your local law enforcement and review their policies and procedures. Hold joint training sessions where EMS providers share their experience in using naloxone and officers talk about the techniques that they can use to secure the patient while care is being given.
Stay safe out there.
[Titrating naloxone through an intranasal dose through a nebulizer and monitoring with capnography can reduce the risks of opioid withdrawal symptoms to the patient and EMS provider. Read more: Bledsoe: Titrate intranasal naloxone to restore respirations]
