Michael W. Dailey

Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing

Abstract Background: Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. Methods: Using data from the National Emergency Medical Services Information System, we examined data from 2012–5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. Results: Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20–29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13–1.22) and for men (aOR = 1.13, 95% CI = 1.10–1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72–0.80 and aOR = 0.85, 95% CI = 0.80–0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68–0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45–3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09–1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). Conclusion: This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs.

The Prevalence of Cardiovascular Disease Risk Factors and Obesity in Firefighters

Obesity is associated with increased risk of cardiovascular disease (CVD) mortality. CVD is the leading cause of duty-related death among firefighters, and the prevalence of obesity is a growing concern in the Fire Service. Methods. Traditional CVD risk factors, novel measures of cardiovascular health and a measurement of CVD were described and compared between nonobese and obese career firefighters who volunteered to participate in this cross-sectional study. Results. In the group of 116 men (mean age 43 ± 8 yrs), the prevalence of obesity was 51.7%. There were no differences among traditional CVD risk factors or the coronary artery calcium (CAC) score (criterion measure) between obese and nonobese men. However, significant differences in novel markers, including CRP, subendocardial viability ratio, and the ejection duration index, were detected. Conclusions. No differences in the prevalence of traditional CVD risk factors between obese and nonobese men were found. Additionally, CAC was similar between groups. However, there were differences in several novel risk factors, which warrant further investigation. Improved CVD risk identification among firefighters has important implications for both individual health and public safety.

Basic Life Support Access to Injectable Epinephrine across the United States.

Abstract Background: Aggressive epinephrine administration has growing support in the treatment of anaphylaxis, a life-threatening allergic reaction. Emergency Medical Services (EMS) providers are frequently in a position to provide the first care to someone experiencing an anaphylactic reaction. Intramuscular injection of epinephrine is the definitive pharmacologic treatment for many associated symptoms. While easy to use, epinephrine autoinjectors (EAI) are prohibitively expensive, having increased in price ten-fold in ten years. Some states and EMS departments have begun expanding the scope of practice to allow Basic Life Support (BLS) providers, previously restricted to noninvasive therapies, to administer epinephrine by syringe. Objectives: To compile a current and comprehensive list of how epinephrine is carried and used by EMS across the USA. Methods: An online survey focusing on anaphylaxis protocols and epinephrine administration was sent to state EMS medical directors and officials in all 50 states. Follow-up telephone calls were made to ensure compliance. Data were analyzed with descriptive statistics. Results: Forty-nine of the 50 states in the USA provided a survey response. Texas responded but declined to participate in the survey because of practice variability across the state. In the other states, the form of epinephrine allowed or required on BLS ambulances was consistent with the scope of practice of their Basic Emergency Medical Technician (EMT). Thirteen states had training programs to allow BLS providers to inject epinephrine; 7 were considering it; 29 were not. Twenty-seven states specified EAI as the only form of epinephrine required or allowed on their BLS ambulances. No states reported allowing any level of EMS provider below EMT to use alternatives to EAI. Conclusion: This study confirms that many states have expanded the training of BLS providers to include the use of syringe injectable epinephrine. Even so, the majority of states relied on EAI in BLS ambulances.

Intranasal Naloxone for Opioid Overdose Reversal.

Received June 5, 2014 from the Network for Public Health Law, Southeastern Region, Carrboro, North Carolina (CSD), Alcohol and Drug Abuse Institute, University of Washington, Seattle, Washington (CJBG), San Francisco Department of Public Health, San Francisco, California (PC), Albany Medical Center, Albany, New York (MWD), and Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts (AYW). Revision received June 24, 2014; accepted for publication June 26, 2014.

Precision of time devices used by prehospital providers.

Background. As many medical, medicolegal, andresearch interests have become more time-dependent, increased weight should be placed on the precision of time documentation andtiming devices. Studies have previously documented poor synchronization of timing devices in the medical setting. Objective. To determine whether any advancement has been made in prehospital time accuracy andto determine the timing devices used by todays emergency medical services (EMS) providers. Methods. Times recorded from the timing devices available for use during calls by local EMS providers, including watches, cellular phones, cardiac monitors/ defibrillators, ambulance clocks, andpublic safety answering points, were compared with atomic time to determine accuracy. Additionally, the preferred provider timing device, andaccuracy of said device, was obtained. Results. A total of 138 available timing devices were observed, with an accuracy of only 36.9%; cell phones had the best accuracy (67.7%). For the 53 providers surveyed, watches (64.2%) were found to be the most used timing device, followed by cell phones (24.5%) andambulance clocks (11.3%). Only 18 (34.0%) of these preferred devices were accurate when compared with atomic time. Conclusions. There is no precision or consistency in the timing devices used by EMS personnel. However, methods are available, such as those that support the cellular phone industry, that would help with consistent andprecise timekeeping. Utilization of modern technologies could increase precision in patient documentation anddecrease medical, medicolegal, andresearch issues relating to time documentation

Enabling Donation after Cardiac Death in the Emergency Department: Overcoming Clinical, Legal, and Ethical Concerns

BACKGROUND In light of the growing gap between candidates for organ donation and the actual number of organs available, we present a unique case of organ donation after cardiac death. We hope to open a discussion regarding organ procurement from eligible donors in the prehospital and emergency department setting. CASE This case study, involving an otherwise healthy man who, after suffering an untimely death, was able to successfully donate his organs, highlights the need to develop an infrastructure to make this type of donation a viable and streamlined option for the future. DISCUSSION Given the departure from traditional practice in United States transplantation medicine, we bring forth legal and ethical considerations regarding organ donation in the emergency department. We hope that this case discussion inspires action and development in the realm of transplant medicine, with the aim of honoring the wishes of donors and the families of those who wish to donate in a respectful way, while using our medical skills and technologies to afford candidates who are waiting for organs a second chance. CONCLUSIONS We believe that this case shows that donation after cardiac death from the emergency department, while resource-intensive is feasible. We recognize that in order for this to become a more attainable goal, additional resources and systems development is required.

Decision-Making in the Moments Before Death: Challenges in Prehospital Care

Abstract Background: The primary charge of Emergency Medical Services (EMS) is to save lives. However, EMS personnel are frequently called to scenes where prolonging life may not be the primary goal. When someone is nearing death, family members may feel compelled to call 9-1-1 because they are feeling uncertain about how to manage symptoms at the end of life. Objective: We sought to explore prehospital providers’ perspectives on how the awareness of dying and documentation of end-of-life wishes influence decision-making on emergency calls near the end of life. Methods: The study design was exploratory, descriptive, and cross-sectional. Qualitative methods were chosen to explore participants’ perspectives in their own words. In-depth in-person interviews were conducted with 43 EMS providers. Interviews were audio recorded and professionally transcribed. Interview transcripts were entered in Atlas.ti for data management and coding. The analysis was deductive and guided by a conceptual model of 4 contexts of end-of-life decision-making that is not setting-specific, but has been applied to prehospital care in this study. Results: The findings illustrate the relationship between awareness of dying and documentation of wishes in EMS calls. The 4 decisional contexts are: (1) Awareness of Dying-Wishes Documented: Families were prepared but validation and/or support was needed in the moment; (2) Awareness of Dying-Wishes Undocumented: EMS must initiate treatment, medical control guidance was needed; (3) Unaware of Dying-Wishes Documented: Shock, expectation that EMS can stop the dying; and (4) Unaware of Dying-Wishes Undocumented: Families were unprepared, uncertain, frantic. Each context is illustrated by representative quotes from participants. Discordance and conflict was found in each decisional context. Conclusions: This study illustrates that EMS providers are acutely aware of the impact of their decisions and actions on families at the end of life. How emergency calls near the end of life are handled influences how people die, whether their preferences are honored, and the appropriate use of ambulance transport and ED care. The findings highlight how the intersection of awareness of dying and documentation of wishes influence prehospital decision-making in end-of-life emergencies and demonstrate the key role EMS providers have in this critical period.

Commentary on “Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care”

A recent MMWR highlights the epidemic of opioid overdose facing the country, with an increase by 14% in the number of people dying from presumably preventable overdose between 2013 and 2014.1 In this mindset I read the paper by Levine et al. “Assessing the risk of prehospital administration of Naloxone with subsequent refusal of care”2 with great interest. I then read an article in the popular press that indicated that law enforcement officials wanted to compel people to treatment if they had received naloxone.3 Fascinating dichotomy – law enforcement compelling people to seek care and EMS allowing people to sign off and stay home. Indeed, when a person has been given naloxone to reverse the effects of opioids, they have gone from the brink of death to mentating normally in a very brief amount of time. Should this give us pause in the process of the refusal of transportation or the refusal of additional care? How should EMS respond to overdose reversals and then what should we do for these patients; is this an opportunity for intervention we should capitalize on? In Europe there has long been a practice of nontransport following heroin overdose reversal4 and this has been documented in the US in both San Diego and in San Antonio.5 In our standard EMS and medical practice, patients with the ability to mentate normally, are not under the influence of intoxicants, appreciate the risks of their decision-making and who are given options for alternative care, may refuse care. Reviewing the outcomes for these patients, indeed any patients that refuse care,6 is certainly a best practice within a system and the medical direction team from

While we dither, people continue to die from overdose: Comments on 'Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures?'.

MAYA DOE-SIMKINS, CALEB BANTA-GREEN, COREY S. DAVIS, TRACI C. GREEN & ALEXANDERY. WALLEY Heartland Health Outreach, Chicago, IL, USA, University of Washington, Alcohol and Drug Abuse Institute, Seattle, WA, USA, Network for Public Health Law, Southeastern Region, Chapel Hill, NC, USA, Boston Medical Center, CARE Unit, General Internal Medicine, Boston, MA, USA and Boston University School of Medicine, Department of Emergency Medicine, Boston, MA, USA E-mail: mdoesimkins@gmail.com

Commentary on Gjersing & Bretteville-Jensen (2015): EMS-treated opioid overdose--an important opportunity for saving lives.

Overdose reversal must be seen as an opportunity for intervention because of the elevated risk of death following the event. While emergency medical cardiac arrest care is a poor parallel for opioid overdose, the need for rigorous review and fiscally prudent solutions is similar. Efforts must be made to look for solutions to prevent and treat future overdose specifically in the population that has had an overdose event.