We can learn as much from our errors as we can from our success.  I share with you a case of multiple errors that we can all learn from.  This is not a judgement but a plea to remember we are entrusted with the care of human life.  It is an honor to be given this ability and we must never forget this.

Case: 

48-year-old male reported by police to EMS, this is a well-known drug abuser who they were doing chest compressions on, after they administered 12 mg of Narcan intranasally.  He remains unresponsive and EMS correctly started to manage his airway with BVM.  An IV was established and he was given 2mg of Narcan IV.  Within a minute he was awake, fighting and could not be controlled.  The crew then administered an additional 2mg Narcan IV.  He became more violent and was now putting the crew and himself in immediate danger, including spitting with one of the crew members exposed to oral contamination.  They recognized the danger and chose to use Ketamine.  They gave 2 doses both IV and the sum of the dose was 400mg.  He also received 2.5mg Versed IV.  No glucose was checked during his care. Fortunately, his glucose was 140 on arrival at the ED   He arrived at the emergency department with snoring respirations as the staff managed his airway.  He was awake in 15 minutes and after observation was discharged from the emergency department.

There is certainly a lot to unpack here.

1.  Police administration of IN Narcan takes at least 8-13 minutes to work.

2. Narcotic OD events with LOC occur because of hypoventilation and retention of CO2.  It would be better to manage his ventilation, than to pour more Narcan down his nose.

3. The response to the 2mg of Narcan was probably the summation of the IN Narcan and the IV Narcan, which has placed this patient into a violent withdrawal event.

4. The worst thing you could do to your patient who is screaming, is to administer more Narcan.  Narcan is to be given with airway and breathing compromise.

5. This is a 48-year-old, all patients with altered mental status must have POC glucose.  Anyone who receives Ketamine for dissociative care must have a glucose check.  Remember Elijah McClain’s death in Colorado when EMS did not check a glucose after Ketamine administration.

6. Remember Ketamine has significantly different effects depending on the route and the dose.  We use this drug successfully due to our commitment to medical direction oversight.  The dose for severe danger and violence is 250mg IM and this can be repeated in 5 minutes with an additional 250mg IM.  Given this level of Ketamine IV is even way over the chemical assisted IV dose of Ketamine which is 1mg/Kg with minimum adult dose of 100mg for intubation.  Remember for every drug even hanging an IV bag (yes, we sometimes grab the wrong IV bags), requires double checking and closing loops.  Right drug, right route, right dose, right time, and right patient brings us towards high reliability care.

We all learn differently, and nothing is harder than learning things the hard way.  We need to sometimes take a deep breath and openly discuss our thoughts of care with our colleagues.  No emergency is so severe that we simply stop using our safety stops.  Remember in this situation there were 6 providers on scene caring for this man.  It does not matter if you are the junior medic or the EMT, if something doesn’t feel right, speak up.  This is a speak up culture and we all have a voice when it comes to doing what is best for our patients.  Thank you for your dedication, caring, empathy and professionalism.