Noloxone...should EMT-I's be able to administer?

[EMTeach]

I am new to this sight and from what I have seen. It seems that there are a few battles of what color patch you wear. I am an EMT-I in UT and the service I work for allows the use of narcan by its very qualified I's. We are lucky that we have a medical director and an AC that believes in our skills and they both are very proactive in getting as much in our box as we can handle. Now on a respectful note I have know some medics that need to go back to EMT-B and I have known some I's 's that shouldn't be allowed to even drive the ambulance or even attempt first-aid. We have rescues that attend to our ALS services when needed but if they are busy we do what is needed for good proper patient care. I guess the point I am trying to make is that no matter what color patch you wear or the education that you have 75% or our calls are BLS calls and we all need to remember if you don't do good basic skills you will never make to advanced care with your patient because they will be dead

[JPINFV]

Therefore, the serum concentration of the narcan is not affected by the serum concentration of the opiate.

Not directly, but the higher the relative concentration, the more likely it will be bound to the receptor and unavailable to be eliminated. Since less of the lower concentration is bound, it will effectively be eliminated quicker. This is not to say when the serum is saturated with Narcan that the rate of elimination of Narcan is low. It is merely inconsequential as long as Narcan continues to out compete the opiate for the binding site.

[kevkei]

Hmmm, interesting way of looking at it ... are you saying then that the harder the narcan has to compete to bind to receptors, the shorter the half life, primarily due to it 'working so hard'? That doesn't make much sense to me, because that would imply narcan is equatable to a living cell using energy exponitiously, when we all know that it's purely a chemical.

Technically however (and I may be wrong here ... but this is how I understand it), serum concentration and half-life refers only to unbound drugs. If the drug is bound to a receptor, depending on the cells activity, it will either be utilized quickly or slowly, and then made available for biotransformation and elimination ... the rest, will simply attempt to find an open receptor and slowly (as I was actually taught narcans half-life is anywhere between 30 and 81 minutes) be eliminated. Therefore, the serum concentration of the narcan is not affected by the serum concentration of the opiate.

peace

Take a patient that has been given two seperate doses of a narcotic but all other things being equal, say 10 mg and 20 mg respectively of morphine. If you administer 2 mg of narcan IVP to both situations, your saying that the effects of the narcan will last 45 minutes in both situations? I say I disagree. The affinity that a drug has for a receptor is influenced primarily by two factors: 1) the natural affinity the free drug has for the receptor, 2) the concentration of the drug. Other factors include things like pH, bioavailability.

In this situation, although narcan typically has a higher natural affinity to mu and kappa receptors than most opioids, it is competing with a higher drug concentration. The higher plasma drug concentration the higher it's said affinity for the receptor site and it's ability to actually remove the narcan from the receptor. This will result in less bound narcan and more free drug, which leads to metabolization and elimination.

[RogueMedic]

To add my two cents, I don't have a problem with Intermediates givig Narcan. Given the current trends towards advancing skill levels and expanding protocols; it seems to be something that is looming over the horizon much like the next war we may have to fight. As an Army Medic, I stress to my soldiers either you increase your knowledge base or someone dies, then I get upset, take it personally and then kill you myself. Boundary lines in the Medical profession have become so obscured that everybody seems to cross into various realms and degrees care these days so it is only natural to let things flow this way. I would take 2 damn good EMTs over a half ass Paramedic any day of the week.

Those who exemplify the skill and knowledge to do advanced procedures in the interest of overall patient improvement, should be granted that consideration.. All Paramedics should remember back when they were EMT-Basics and were regulated to "Gopher" status yearning to be on the cutting edge that which was reserved for Paramedics, Nurses etc. But as the old saying goes "Paramedics save lives, EMTs save Paramedics." why shouldn't they be allowed to help where they can. There is already a shortage of Paramedics out there and an even greater shortage of GOOD Paramedics with the street sense to keep from killing people. I say accept the help from whatever source it may come from. Besides, isn't it our job to always try to more for the people we serve? That's just my two cents.

Leslie W. Brock Jr., EMT-P

Operations Manager

MedZone EMS

[Nate]

Just thought I would throw this little bit of information in. Most EMT-I classes taught by colleges here in Texas do cover the use of Narcan by the EMT-I.

[medic001918]

Those who exemplify the skill and knowledge to do advanced procedures in the interest of overall patient improvement, should be granted that consideration.. All Paramedics should remember back when they were EMT-Basics and were regulated to "Gopher" status yearning to be on the cutting edge that which was reserved for Paramedics, Nurses etc. But as the old saying goes "Paramedics save lives, EMTs save Paramedics." why shouldn't they be allowed to help where they can. There is already a shortage of Paramedics out there and an even greater shortage of GOOD Paramedics with the street sense to keep from killing people. I say accept the help from whatever source it may come from. Besides, isn't it our job to always try to more for the people we serve? That's just my two cents.

Leslie W. Brock Jr., EMT-P

Operations Manager

MedZone EMS

As a basic, I did yearn to be on the cutting edge reserved for the higher level of care. Guess what? I did something about it. I enrolled in a paramedic program, studied non-stop and became a paramedic. My desire to be on that edge was fulfilled w/o taking any shortcuts. It's the proper education thing.

As far as the "Paramedic save lives, EMTs save paramedics" statement, that was recently picked apart here. Do we need to go through that again? I think it was pretty well shattered last time it came up. While you're right that I'd rather have two competent basics instead of a lazy medic, a paramedic is still the higher level of care with more training and education to draw from in the decision making process. They SHOULD be making better decisions and intervening more than a basic can and does.

Shane

NREMT-P

[Lithium]

Ahhh, I get what you're saying. I think I'll just have to agree to disagree. Even though there's many factors which affect a drugs affinity for receptors, I don't think the serum concentration of what it's competing against is really an influence. Mainly due to the fact that the narcan is not competing against the morphine in a one on one situation. All the narcan is doing is looking for a receptor to bind to.

If anything, I would think the other factors you mentioned would be more of an influence (bioavalability, temperature, pH, paCO2 etc ... )

peace

[hammerpcp]

Hammer, I think you just proved exactly why BLS personnel should not have access to ALS meds ... If 2 mg of Narcan hasn't shown a response, either every potential receptor is already occupied, or there's something much more serious going on. If that's the case, securing the airway and maintaining adequate ventilations is now my top priority. Not that it wasn't before, but as I previously stated, if I can eliminate the problem, I will. The line of thinking of "well if 2 mg isn't enough, I'll just call for more" is a little skewed. And yes, I do know of patients who've received much more, but that was in-hospital with a lot more resources available.

Yes, narcan has a shorter half-life then opiates. However, it is an antagonist, meaning, it will compete for receptor sites. If there's still sites available, it will bind to them, lessening the effects of whatever the patient took essentially by having less receptors for it to bind to and letting the others already bound wear off.

Sorry if I'm not making things clear ...

peace

Lithium,

"2 mg isn't enough, I'll just call for more" is not my thinking. I hate to repeat myself, so please reread my previous post. And no, you are not making yourself clear. You are in fact contradicting yourself by saying in your original example scenario that the pt did respond to narcan and then later that they did not. OH..there i go repeating myself. Anyway, to state that BLS providers should not have access to ALS meds is quite a broad and self important statement to make. Especially since up until now you have not been able to substantiate it.

[hammerpcp]

:shock: what i think is really bad is that some paramedics that are fighting this thread and stating that Intermediates are crying for more drugs, skills, or whatever.... are hipocrites. Here's why: At some point, a group of paramedics did question adding skills and/or drug use for themselves. Why would they do this? To learn...and to be more valuable on the street. After a while, the MDs were convinced to give paramedics a bit more education and allow them to practice more skills/drug therapy. We know it wasn't a group of MD's that got together and decided to dump these skills on paramedics! They asked for it and they got it. Now the same principles are being attempted by some Intermediates who want to take another step in education and practice skills to be more valuable on the street. Nothing ever said that they weren't going to move on to paramedic, but not everyone starts at age 18 going to basic and goes straight through paramedic in a few years (like one medic I know on this site). Most people i know want to get some street experience between each cert level so they can use that experience to help learn.

So WHY are paramedics so against a learning process that they have gone through in the past??

Well said. =D>

Let me dumb it down some more for those of you who still don't get it. Medicine is a constant balancing act of harm vs benefit of any given treatment or procedure, be it medication, intubation, IV starts, etc. For any of you to say that any particular procedure or treatment is absolutely not acceptable for any particular level because "that is how it's always been" is sooooo ignorant. (Can you say paragod complex?) Let's aim for progress in this field here people, not stagnation. As of yet no one has given a good reason why sufficiently trained (or educated whatever you want to call it since the two words are really interchangeable) individuals should not be allowed to administer Narcan. On the other hand several very good reasons have been given supporting appropriate administration of this drug.

[medic001918]

Really? Where? I think I missed that part. Since most of the sound reasoning has been against the administration of the drug by EMT-I's. One of the largest reasons is that the majority of EMT-I courses don't cover enough A&P and pharmacology for them to be administering the medication. Add that to the fact that their ability to manage the potential side effects is not in place, and you have reasons (repeated once again) for why they should not give the medication. I'm still with the others, it's a paramedic level drug. Call it a god complex or anything else you want. If you want the advanced interventions, go obtain the proper education and certifications/licenses. No shortcuts.

Shane

NREMT-P