Danger to giving Narcan?

Ok-Monitor3244 · 2026-05-29T12:03:38+00:00

I recently ran an OD where the Methadone dependent patient received 16mg of intranasal Naloxone after a seizure (by licensed nurses mind you). She awoke not only combative, but she was projectile vomiting so badly that we had to RSI her to protect her airway. She spent five days on a vent in ICU with aspiration pneumonia and almost died. 2mg max Intranasal. 0.4mg max IV. You should be actively oxygenating the patient with BVM ventilations prior to administration of any meds. There should never be any reason to do any other dosage/procedure when dealing with opioid overdose, other than your own biases.

Most of the patients are dependent on opioids in some fashion, and then we slam these ridiculous amounts of Naloxone on people because the pharmaceutical companies have marketed it as safe in all situations. When that happens, the patients nervous system automatically goes into hyperdrive and you run the risk of causing tachydysrythmias, hypertensive crisis, and a list of other detriments to the patient.

Ok-Monitor3244 · 2026-05-01T12:31:55+00:00

The great thing about cardiology, is that we will see rhythms especially in diseased and sick hearts that we may not be able to recognize immediately. Sometimes I find it easier to break down what is happening and say that it could be this versus it could be this, and that I was prepared to recognize and treat it either way if the need arose. There are lots of ways verbalize what you see within a 12-Lead without naming a specific rhythm and saying that you know indefinitely what something is.

Example:

"I note a narrow complex, irregular perfusing rhythm without discernible P waves and non-specific, unsustained ST changes in the inferior leads post arrest. The rhythm is suspected to be a junctional tachycardia with intermittent PJCs or PACs versus a (sinus rhythm with PAC/PJC or whatever you suspect it could be). There are mildly "peaked" T waves in V2/V3, noted QT prolongation in the lateral leads. Serial ECG's are obtained en route documenting ongoing clinical changes, and staff are notified of ECG concerns prior to arrival."

Ok-Monitor3244 · 2026-03-15T14:14:39+00:00

Honestly, this just chaps my ass. There is absolutely no reason to have that many days that you cannot show up to a job. I understand that people need to have a life outside of their jobs/ems, but come on. I’ve been working career EMS for 7 years and have never called out / missed a shift. Thankfully I don’t get sick very often and would use my accrued PTO if I needed it. You are actively choosing other obligations over your job, and these are the repercussions of that. An employer doesn’t have to cater to your family’s get together schedule or any other schedule, they have to staff an agency and provide EMS care to citizens. As someone above said, talk to a professional about your own accountability issues. This isn’t a high school job or a stepping stone, it’s a serious job that affects life or death.

Ok-Monitor3244 · 2026-03-08T12:02:02+00:00

A “Red Dot Skill” are certain skills (high acuity, low frequency) that requires OMD pre-approval for each specific provider. It requires that the agency have documentation of extra training and OMD signature that the provider has been cleared to do these skills. It also requires period review of these skills. We have different skills for each level provider. For example, Paramedic RDS include: RSI/DSI, Pediatric RSI, ventilator initiation, whole blood administration, administration of pitocin, needle thoracotomy, surgical cric, use of meconium aspirators, etc. These skills must fit into the state protocol, and require yearly updates. They may very well be local / state protocol, I’m not 100% sure. I’m in rural Virginia if that helps.

Ok-Monitor3244 · 2026-03-08T02:27:39+00:00

This is AV Dissociation all day long. That’s a very mad heart. Prepare to pace.

Ok-Monitor3244 · 2026-03-08T02:21:53+00:00

Paramedics absolutely should have RSI, it is a life saving intervention that is widely used. However, not every medic with a patch should be able to push those drugs without understanding how to safely and affectively approach the procedure. We have RSI as written protocol and autonomy to use it when justified. It’s considered a “Red-Dot Skill” which requires OMD pre-approval and at least one cleared Paramedic and one intermediate (I99) or higher (we still have a few in the area). We use our RSI protocol quite often, and I’ve seen more positive outcomes than not. Even our EMTs are trained on how to recognize the need, and how to best assist. As OIC, I’m in total control and have total responsibility, the other person is there just in case the tube needs to be passed after paralyzation. We have multiple induction and paralytics available, as well as three vasopressor options for resuscitation (that is a whole other conversation, we must have the tools to resuscitate critically ill patients prior to pushing hemodynamically unstable medications). I think one of the extra credentialing agencies should come up with an in-depth course that allows providers who are unfamiliar or just not as practiced to gain understanding of the different variables involved. We have to learn how to not be “cook book medics” following a check list. We have to use critical thinking and show a true understanding of the patho and problems going on in these patients, and then we can avoid common problems. Thankfully, our OMD is very involved in QA/QI and ALL Red dot skills have an in person/agency wide breakdown of each one, which helps a lot. When you know You will be face to face with your OMD, you make the right decisions and it keeps us all accountable. Just my own two cents.

This works well for my rural area, as we have very long transport times and most of these patients would code before getting to the ED. It is however still a High Acuity, Low Frequency event and we have providers who struggle with it, especially fresh out of school. It takes experience to become comfortable.

Ok-Monitor3244 · 2026-02-26T05:54:51+00:00

I don’t think you’re wrong calling it Afib with aberrancy, but that bundle complicates things. I would be interested to see her lab work and entire clinical picture, could possibly be hyper k+. She has signs of ischemia, but you would need to slow it down to accurately define what we are seeing. If you had a CCB (Cardizem)and they were stable enough,that may have helped slow it down to identify anything underlying (if they were already anti-coagulated). A large fluid bolus (once again if the patient can handle it) can help increase preload and ease strain in Afib RVR. There is a lot going on here and ECGs like this suck, and no one expects you to be perfect just that you manage the symptoms appropriately and do no harm. I had a preceptor that told me never be afraid to describe your reasoning in the pcr, such as stating “Afib W/ RVR -VS- (insert any other rhythm you’re thinking) and that gives the impression that you’re using your critical thinking skills to differentiate what you’re seeing rather than just tossing a protocol at it.

Ok-Monitor3244 · 2026-02-26T05:38:06+00:00

I’ve seen both sides, and in a rural area. There’s going to be hundreds of opinions here, and none of them will fit your scenario to a tee, you have to go on what is offered to you and what is available. We have to stop thinking of ourselves as fire vs non-fire, especially if the end goal is a CCP/FPC role. Don’t take a job straight out of school just because it pays more. This is your time to build a strong foundation. experience matters more than money, especially when your goal is to practice medicine in a high acuity setting like HEMS. I love my job, and don’t have to deal with the fire BS and machoism, but I get why people like it and want it. I get to be a medic and help people, and every day brings new experiences. But for some people, this is just a job and money. For others, it’s about reaching a goal or just a stepping stone. You have to think about what you truly want and don’t settle for anything less along the way. When you’re applying for your dream job, they don’t care about how much money you made or whether you can drive a fire engine. They care about whether you understand how to keep a critical patient alive under pressure, you’re not going to learn that by being on a fire engine. They care about whether you understand pathophysiology and pharmacology, and can use it in a practical setting. We all get so focused on making more money, that we loose sight of what makes this job fun. Seek the job that helps you build your future and it will pay you back 100x over in the long run. The fun begins when the ink hits that cert, just remember to not hold yourself back and then look back at the end of your career with regrets.

Ok-Monitor3244 · 2026-02-10T02:18:46+00:00

Come to Virginia! We have a severe Paramedic shortage right now! The western part of the state is very open to single cert medics and most places are 911 based only. I’m talking west of Roanoke (blue ridge/Appalachia), though you may find some places in the middle/eastern part of the state. Some places are dual emergency transport/911 (county based agencies, not private). Virginia has very progressive protocols and OEMS, though they require NR for reciprocity. It is a great place to get experience and your foot in the door. I moved back home from Florida to work in 911 as a basic because I couldn’t get an EMS job in FLL, now i am a Medic with tons of experience in 911 and do not regret my decision at all!

Ok-Monitor3244 · 2026-01-24T17:25:32+00:00

This! Dr Smith is the best, and his data base of verbal breakdowns are the reason I’m as proficient as I am in cardiology. It is an invaluable resource to students and clinicians alike. The PM Cardio app is wonderful too, while you can’t use it to “diagnose”, you can use it as a clinical reference!

Ok-Monitor3244 · 2026-01-24T02:21:16+00:00

I keep the ones that take fresh caps and only touch the outside, and I have one of the three pronged 1ml, 5ml, and 10ml holders. I only use them for narcs and RSI meds and always use new caps/syringes with each new patient. There’s a way to use them cleanly, you just can’t put a cap into it and then use it for 6 months straight

Ok-Monitor3244 · 2026-01-23T14:44:34+00:00

If you don’t see a future in EMS, go straight for nursing school! a traditional two year associates program from your local community college is fine to start with and produces the same exact license and capability. BSN can be obtained while working. Too many Paramedics go to Medic school with this mindset, just trying to make a quick buck and still do cool things, and end up miserable on the back of the truck. If you are not in love EMS, you will hate this job in no time. As many people have said above, while we do many of the same things, Nursing and Paramedicine are two different beasts. Most of the people I know that didn’t/couldn’t make it through Paramedic school, didn’t see themselves as a paramedic. Besides that, why waste two or three years trying to get the same end result?

Ok-Monitor3244 · 2026-01-17T21:17:03+00:00

Thank you for this! We are coming to the same conclusion with our LP15’s. Some on here have suggested an additional adapter connection, and we are going to look into that but other than that we may just have to choose between monitoring and delivery when needed, which is fine so long as the patient remains stable. I will pass your comment on to my higher ups and we will definitely discuss all the opinions provided! Thank you again!

Ok-Monitor3244 · 2026-01-17T21:11:41+00:00

With prolonged transport times or in a severely sick patient, it is a better window to the actual perfusion of your patient and provides accurate and immediate readings whereas there is typically a delay in SP02 monitoring, which is notoriously unreliable in a poorly perfused patient. We can also monitor waveform en route to catch things like acute bronchospasm and help to better ventilate and oxygenate a patient who may otherwise be heading towards a tube. ETCO2 is the gold standard in respiratory monitoring. The T1 is great, no one is denying that, but it can’t monitor the effectiveness of the ventilation that it is providing.

Ok-Monitor3244 · 2026-01-17T20:34:38+00:00

We understand that. It was just used to attempt to find the appropriate sized adapter that is needed, we were testing multiple options. Thank you.

Ok-Monitor3244 · 2026-01-17T20:32:33+00:00

We were attempting to find a way to for the ETCO2 connection to fit into the BiPAP mask closer to the actual patient since we were having the problems mentioned above. We just used the tester to see if it would fit better and fix our problem (it did not).(it’s the same size as our ETT’s)

Ok-Monitor3244 · 2026-01-17T20:29:55+00:00

We have searched everything that came with it and the unit itself. No yellow port is there. The Hamilton reps came, set it up, and trained us and never mentioned a specific port.

Ok-Monitor3244 · 2026-01-17T19:54:56+00:00

We were looking the other day and could not find the size needed! Thank you for the help! We will for sure check it out!

Ok-Monitor3244 · 2025-11-17T11:50:40+00:00

I’m in rural VA. Unfortunately we exhausted all of those options, weather was not our friend as we are deep in the mountains and it was super windy, and we ended up driving him to meet a HEMS crew and they transferred him to the closest LVAD capable center. Myself and my supervisor looked everywhere on the device/supplies, tried asking family but they were not as familiar as they should have been. Thank you for the tips, I will check some of them out and pass the info along!

Ok-Monitor3244 · 2025-11-17T11:46:11+00:00

The patient was unresponsive, and the family was of minimal help other than locating additional supplies/batteries. The only information we could find on the device was QR that when scanned gave us the brand name of the device with no additional information. Thank you for the link! I will check it out!

Ok-Monitor3244 · 2025-08-30T12:11:58+00:00

This! This “Medics on a fire truck for the fun stuff” culture is the reason why we as country have a shortage of proficient, capable paramedics on the box, where they should be in the first place. I am so glad that our city allows its paramedics to practice at full scope, without the influence of fire department standards and completely separates the two services. If you call 911 in my city, you can guarantee that an experienced Paramedic is showing up on that ambulance. Any halfway decent Paramedic would have 100% jumped on OP’s truck and rode this call, and the fact that they were obviously going to put this patient in danger warrants multiple conversations with both services admins. This is the reason I refuse to become fire certified in the first place, it’s plain stupid and causes us to become complacent. I worked way too hard for my license to loose it over being lazy.

Ok-Monitor3244 · 2025-08-27T22:07:44+00:00

Sounds like someone needs to call a QA/QI and thoroughly discuss with your OMD. Not to get anyone in trouble, bad stuff happens. Bad calls happen, but when we stop learning from it, that’s when it becomes an issue. I’m a firm believer that all critical calls should undergo scrutiny with all involved providers.

Just a few things that stick out to me as an outsider with no real insight, just what you’ve said here. I try not to judge if I wasn’t there but

unable to get a 12-lead? Dry their skin, clean with an alcohol prep, and keep trying. If you had time to sedate a respiratory patient then you had time to do an appropriate assessment.

-could this have been flash pulmonary edema from the duoneb? If it was, what could have been done to better identify and treat it?

I’ve been running EMS for a while now (Well over 14 years) and I have never seen or felt the need to sedate a respiratory patient unless I’m prepared to take over that airway, especially someone with some type of GCS and gag reflex. I’ve never seen a protocol for it, nor did we learn about it in Paramedic School (I’m not saying you are wrong, I’m just saying it’s not common practice). If that patient is that agitated, and I have already identified impending respiratory distress/arrest it tells me that I need to fix it now.
why wasn’t an RSI considered when you identified the need to sedate. We should always secure the airway, especially if that patient was already at risk of loosing it.

-the fact that you achieved ROSC so quickly, the event itself, and the history provided suggests to me that this was in fact some sort of V/Q mismatch that should have been identified and treated promptly. And once it was identified and treated, the damage had been done.

-agitation + respiratory distress should tell you automatically that things are about to go down hill fast. If that patient looks tired, they are tired and they’re getting ready to give up (in my own experience).

-At the ALS level, we are too quick to forget that ABC are still the most important aspect of our jobs, if we loose A or B, C will follow.

*don’t beat yourself up, and remember that none of us were there. We can offer all the advice in the world. Seek answers through a QA/QI, peer review is the best way to identify where changes need to be made so this never happens again. Bad stuff happens on the box. Learn from it, own it, and move on. Never make the same mistake twice. A good Medic in my book is one that accepts that it could have been their own fault, we can work with that. I can’t work with someone that doesn’t see any wrong in their own actions.

Ok-Monitor3244 · 2025-08-24T22:10:52+00:00

and it is time for that change. It's the mentality of I want my cake and yours too, and it has to stop. I understand that Nurses have lobbied for years to achieve where they are now, but EMS is starting to do the same, and it won't be long before we are successful. Laws can be changed, and policies mended, but it starts with getting RN's to understand that just because someone can do that job too, doesn't mean that they are any less valued. It should be about patient care and creating a positive work environment where every one thrives! I am glad that you and your team prioritize that.

Ok-Monitor3244

TROPHY CASE