That is the question. And the answer is "Not".
The call came out just after midnight for decreased level of consciousness. I hate hearing that, because it's a pretty generic complaint. Decreased LOC can mean anything from drunk to dead, with a whole lot of stops in between. It always poses a diagnostic challenge, because the patient can't really answer your questions. If the family isn't there, or doesn't know all the details, I get to play "House", and start throwing assessments at the patient until I get lucky and identify a correctable problem.
So- today's patient is a 55 year old female, and a medical train wreck. Multiple abdominal surgeries, back problems, celiac disease, fibromyalgia, migraines, and a laundry list of other issues. There's an equally imposing list of medications including amitriptyline, methadone, a fistful of blood pressure meds, and an SSRI antidepressant. For my non-EMS folks, methadone is not at all an unusual pain medication. It's normally reserved for either exceptionally severe pain, or pain that isn't responding to other medications. The normal methadone patient has either been on pain medications for a very long time, or isn't able to tolerate the dosages of other meds that would be required to manage their pain. Usually this means a cancer patient, someone that's had extensive orthopedic work done, or a long-time fibromyalgia patient that's not responding to other therapies. Most people think of methadone as something used to wean people off of heroin (An exceptional analgesic in its own right, with a horrible image. It's legal for terminal patients in some other countries, I wish it could be used here.), and not as a tool for pain management.
Presentation is a little unusual. The patient has been seated on the toilet for approximately three hours, which isn't entirely unusual for her. She's slumped forward, sleepy, and drooling a little. Blood pressure is 80 by palpation, heart rate is 80. Blood sugar is fine at 94. There's no history of recent acute illness, no new meds, none have been discontinued, and no dosages have changed. Because the patient is in an upstairs apartment, the stair chair is used to move her to the ambulance, parked right outside. When she's laid flat on the cot, she becomes more alert as blood flows northward to her brain. So far, we're considering a cardiac dysrhythmia, CVA (stroke), or medication reaction. Mainly because those are the three most likely diagnoses. Keep it simple, right?
In the unit, the monitor is applied, as well as a 12 lead EKG. Normal sinus rhythm, with no ectopic beats, and no ST segment changes. Normal. IV access is established, and a Cincinnati Stroke Screen is negative. That leaves us medications. Pupils are constricted at 3mm, and sluggish. Now I'm pretty sure we're overmedicated. The respiratory rate is slow at 8-10 per minute, but oxygenation is good, with a room air saturation of 95%. O2 is applied at 4 liters by cannula anyway. I opted to not give naloxone (A narcotic reversal agent.) since the patient was oxygenating well. No need to overwhelm pain meds she obviously needs just to wake her up for the ride to the ER. She's awake enough to maintain her own airway, and that's good enough for me. Naloxone has a greater affinity for the opiate receptors in the brain than most narcotics, so when it's given, the patient can potentially spend hours in pain waiting for the receptors to open back up so the narcotics will work again. I don't believe in torturing patients, so I didn't give it.
Transport was uneventful. I gave a fluid bolus of normal saline. Breath sounds were clear after 250 cc's, but blood pressure remained low, so I continued to run the IV wide open. After about 400 cc's, the patient began having wet lung sounds, so the fluid flow was stopped, and the head of the cot was elevated slightly. When I called report, the RN I talked to , who happens to be a former paramedic himself, agreed with my assessment and my decision to not give naloxone. Unfortunately, he was not the nurse that had the patient in the ER. The nurse that had the patient zeroed in on the pulmonary edema (Wet lungs.), and completely blew off the possibility of overmedication. Never mind that the pulmonary edema is possible with narcotic overdose, slow respiratory rate, shallow respiratory depth, and excessive IV hydration, all of which were possible. Her excitement spread to the doctor on duty, who began wondering if there was some other acute issue. He's got a lot of experience, and tends to not get excited easily, so I began wondering if I'd missed something.
The patient was moved to the major room, and there was some discussion of intubating the patient. This really concerned me, because I'd pictured something more like admission to a monitored bed, maybe ICU, an apnea monitor, and let the patient sleep off the meds. Intubation and a ventilator would certainly protect her airway and keep the patient well oxygenated, but it would also dramatically increase the risk of pneumonia in an already fragile patient. The former paramedic and I both thought a small dose of naloxone would probably do the trick, and he was able to convince the doc to let him give it. Lo and behold, after the naloxone took effect, the patient's level of consciousness improved, respiratory effort improved, and she was able to cough forcefully and clear her lungs. Everyone calmed down, and the doctor made the comment that he shouldn't be afraid to try reversing the effects of meds if the alternative is intubation.
In emergency medicine, we have so many new and cool toys that we often forget to start simply. Our desire to fix the problem can cause us to take a very aggressive approach to treatment of things that will usually clear up on their own if they're given enough time. Obviously, there is a definite time and place for an aggressive resuscitation, and when you get there, you shouldn't hesitate to use every tool at your disposal. The rest of the time, you need to remember the very first thing you're taught in paramedic school. Primum Non Nocere. First, Do No Harm.
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