Your Captain Speaking: ‘Just Another Overdose’

Evening shift. Ride-along paramedic student, so it’ll probably be slow. It seems only a few minutes before tones drop for a cardiac arrest. Turns out to be far from an arrest. Then another call for the same thing that’s not much more than good drama. 

Samantha hears the tones drop for another unit to respond to, you guessed it, a cardiac arrest. “Let’s go head that way to back them up.” They pile into the ambulance and know the location well. Police department on scene, things seem OK. Then the call comes in advising of a second cardiac arrest at the location…then a third. And about a minute later, “Be advised there is a possible fourth cardiac arrest at the location. Mutual aid is being requested.”

Even more will come tonight. The overdoses just keep coming. 

Samantha calls on-scene to a men’s club only a few moments after the primary unit arrives. Police and security are gesturing in multiple directions. Zekia is the paramedic in the first unit, her head on a swivel, checking out the scene—people are pointing inside the building. She quickly locates a very large male, 350-plus pounds, in a very small room and totally unresponsive. Police have started chest compressions.

Samantha initiates Incident Command and tries to organize the scene. Those of you who have started IC know things are rarely initially described as “organized.” Local hospitals are contacted to coordinate how many patients they can handle. Arriving mutual aid is assigned tasks. 

There’s an unresponsive, scantily dressed female being treated with Narcan who suddenly becomes responsive and takes off running through the club without any clothes. Zekia races in pursuit. The club never shuts off the music or turns on the lights—the show must go on. This patient has the hallmarks of a drug overdose: pupils pinpoint and responsive to Narcan. 

There is a second unresponsive male patient found in a bathroom. With Narcan delivered he becomes more responsive, along with vomiting. 

What’s the Story?

Lots of first responders go out on drug overdoses. How was this situation different?

We work constantly with only a fraction of the information we need from the start. You respond to “difficulty breathing” only to find, when you ask a family member, that the patient’s history includes active tuberculosis. This might change your idea of what precautions you need! The same lack of information happens in a “possible overdose.”

What does the CDC say to wear at an overdose? Part of the problem is that we often don’t know it’s an overdose until we’re on scene! The CDC says of fentanyl, “Potential exposure routes of the greatest concern include inhalation, mucous membrane contact, ingestion, and percutaneous exposure (e.g., needlestick).”¹ Notice what isn’t there: skin contact!

We know heroin causes opioid overdoses. The next cousins are the “opioid analogs.” Take a basic opioid and tweak the chemistry a little, and now it’s an opioid analog. Fentanyl is stronger than morphine by about 50–100 times. A stunningly small amount is needed for an overdose. When street drugs are made, it’s very difficult to mix the correct amount of an opioid analog, as the scales and equipment can’t measure that small of an amount. Poor quality control means lots of overdoses. It doesn’t take much. Take a wet toothpick and put it inside a packet of Splenda sweetener. When you pull it out, there will be Splenda particles on the toothpick—hard to see, but they’re there. Had they been fentanyl, they’d likely have been enough for an overdose. 

What about skin contact with the powder? Possible but not so much. The pharmaceutical companies had a hard time developing a fentanyl patch that would deliver the drug transdermally in a predictable manner. Liquify the fentanyl, and there’s no problem getting across the skin. Touch it and then your nose, mouth, or eyes, and it’s likely on its way to your central nervous system. The CDC also says, “Skin contact is also a potential exposure route but is not likely to lead to overdose unless large volumes of highly concentrated powder are encountered over an extended period of time.”¹

Would it surprise you to learn all the people involved in this story tested negative for opioids? How could that possibly be? They responded to naloxone (Narcan), so wouldn’t it have to be an opioid? Here’s the problem: A standard blood test panel will show results for heroin but not fentanyl or stronger opioid cousins such as carfentanil or sufentanil. Drugs such as these must be tested for specifically. 

What’s the take-away? Opioid analogs are way too fine a powder to easily see and avoid on scene. Exposure through intact skin is unlikely, though there are situations when the CDC recommends increased protection. Be ready for anything and continuously reassess your scene anytime you respond to “just another overdose.”

Reference

1. National institute for Occupational Safety and Health. Fentanyl—Preventing Occupational Exposure to Emergency Responders, www.cdc.gov/niosh/topics/fentanyl/risk.html.

Dick Blanchet (ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Samantha Greene has been a paramedic, field training officer, and operations supervisor for Abbott EMS of Illinois for the last 10 years and a lieutenant for the Madison (Ill.) Fire Department for the last five.