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alex104
08-10-2006, 04:06 PM
When would you use them- if ever. I don't recall any discussion on the use while in class and haven't see nor heard of anyone using them on the "street".

Are they a No No in our world?

Thanks
Alex

FireMedAS
08-10-2006, 04:31 PM
Dr. Bledsoe wrote an article a couple of years ago that was critical of ammonia inhalants. What purpose do they serve? If you ask paramedics who use them, they say something like "to see if the patient is faking" or some other such nonsense. Response to noxious chemicals is nondiagnostic from a medical standpont. It's also a draconian way to wake someone up. Leave them in the drug box.


When would you use them- if ever. I don't recall any discussion on the use while in class and haven't see nor heard of anyone using them on the "street".

Are they a No No in our world?

Thanks
Alex

leylandauto
08-10-2006, 05:41 PM
Geez, maybe I am showing my age but I have found them to be another tool in the box. There are lots of tricks to check for faking (eyelash brush, hand drop, sternal rub etc). There are some pretty good fakers out there and sometimes the 'reasonable' use of an ammonia inhalant has helped. There are those out there who may be adolescent over use them to 'punish' the person. Deal with the problem person do not limit the use of the tool.

If you can give me some good reasons medically why the limited use of ammonia inhalants should be discontinued please let me know. I did not get Bledsoe's article. I can always learn. :-)

FireMedAS
08-11-2006, 06:01 AM
The article is called "This procedure stinks: the hazards of ammonia inhalant use." I will look for the article, but in the meantime, why don't you give me some good medical reasons why noxious chemicals should be held under a patient's nose? What evidence do you have to show that a response to ammonia inhalants is in some way therapeutic or assists with the differential diagnosis of a patient? I saw them used just last week on a acetaminophen overdose. What it accomplished I am still trying to figure out.


Geez, maybe I am showing my age but I have found them to be another tool in the box. There are lots of tricks to check for faking (eyelash brush, hand drop, sternal rub etc). There are some pretty good fakers out there and sometimes the 'reasonable' use of an ammonia inhalant has helped. There are those out there who may be adolescent over use them to 'punish' the person. Deal with the problem person do not limit the use of the tool.

If you can give me some good reasons medically why the limited use of ammonia inhalants should be discontinued please let me know. I did not get Bledsoe's article. I can always learn. :-)

Weruj1
08-11-2006, 06:10 PM
while not something we have used in a LONG time we did use one yesterday when the pt failed the "arm drop test" and had a pulse in the 80's and a good EKG & SPO2 with a good BS. Narcan bolus no change...so we tried the inhalant............and poofed it did work. Also the pt did pass "my" test ......took the ol nasal airway without flinching. Needless to say the pt was fine and at home today when I stopped to drop off a medication we forgot to leave at the ER.

firespec35
08-18-2006, 10:51 AM
It's another way to awaken someone. I occasionally us them to arouse my ETOH patients (I work in a nightclub, Yes EMS in a nightclub, I get alot of them). I know I gotta do what I gotta do but I prefer them to performing a sternal rub on women.

montet202
08-18-2006, 12:28 PM
They work. They are harmless. They leave no mark. They are unpleasant, but so is a sternal rub. So what is the problem?

leylandauto
08-18-2006, 12:37 PM
Hi FireMed, I was not trying to be a smartass. I do try to learn from new medicine and change with the times when needed. I do respect other opinions also.
I guess i use the tool from time to time. Commonly we have residents of the local correctional facility who 'lose conc.' If I can wake them up and cure them it saves having to do CAT scans etc to dx this persistant uncon.

At some point, some person on the chain is going to have to do some proceedure to convince this person to open thier eyes.

You can do plenty of tests to see if they are faking but how do you then get them to stop?

I am open to different ideas. I have to deal with this quite often in my daily pt population.

For those who do not use them, what do you use for the person faking? that is not a 'noxious stimula'?

FireMedAS
08-18-2006, 01:14 PM
They only "work" if your definition of "working" is "making the patient withdraw from the stimulus." What exactly do you think you've accomplished? It rules out NOTHING. And they are not harmless. That was the entire point of Dr. Bledsoe's article. Patients have sustained chemical burns to the eyes and they have triggered asthma attacks in those who are susceptible. The first rule of medicine is "do no harm." You should therefore have a clear rationale for any procedure you perform. What about holding noxious chemicals under a patient's nose benefits the patient? A moderate sternal rub is more than enough to establish that a patient is either unconscious or has an altered level of consciousness and is not just sleeping. What more do you need to know? What evidence do you have that response to noxious chemicals under the nose indicates a benign versus a serious problem? The "problem" is that this is bad medicine.


They work. They are harmless. They leave no mark. They are unpleasant, but so is a sternal rub. So what is the problem?

FireMedAS
08-18-2006, 01:25 PM
In my opinion, it's not our job to determine that a patient is faking (not that response to ammonia establishes that). And if they are faking, so what? Can we agree that we have a psych patient? If you have your doubts, say so to the receiving hospital, but if you allow a patient to sign a refusal based on a response to ammonia, all you've established is that your patient did not have the present mental capacity to sign it.


Hi FireMed, I was not trying to be a smartass. I do try to learn from new medicine and change with the times when needed. I do respect other opinions also.
I guess i use the tool from time to time. Commonly we have residents of the local correctional facility who 'lose conc.' If I can wake them up and cure them it saves having to do CAT scans etc to dx this persistant uncon.

At some point, some person on the chain is going to have to do some proceedure to convince this person to open thier eyes.

You can do plenty of tests to see if they are faking but how do you then get them to stop?

I am open to different ideas. I have to deal with this quite often in my daily pt population.

For those who do not use them, what do you use for the person faking? that is not a 'noxious stimula'?

FireMedAS
08-18-2006, 01:27 PM
Congratulations! You sure showed that patient!


while not something we have used in a LONG time we did use one yesterday when the pt failed the "arm drop test" and had a pulse in the 80's and a good EKG & SPO2 with a good BS. Narcan bolus no change...so we tried the inhalant............and poofed it did work. Also the pt did pass "my" test ......took the ol nasal airway without flinching. Needless to say the pt was fine and at home today when I stopped to drop off a medication we forgot to leave at the ER.

FireMedAS
08-18-2006, 01:28 PM
Hey! That's a much better idea than not serving intoxicated patients! Good job! Do you hand them their car keys, too?


It's another way to awaken someone. I occasionally us them to arouse my ETOH patients (I work in a nightclub, Yes EMS in a nightclub, I get alot of them). I know I gotta do what I gotta do but I prefer them to performing a sternal rub on women.

leylandauto
08-18-2006, 02:09 PM
Whoa. I never said anything about signing the pt off after they woke up.

My question remains. What does a medical professional (no matter where they work or what they do) do to make a pt stop faking and for them to open thier eyes and eventually leave the hospital after they have been ruled out of other issues? Just a question that eventually has to be answered by someone in the treatment timeline.
We could just leave the pt alone, do the usual stuff for comas and transport but is that very efficient when it comes to cost containment and utilization review? We do try and work with the people at the hospital to make healthcare flow a bit better. If the pt is awake and talking clearly at time of delivery to the hopsital have we not now saved pretty big bucks in medicaid costs and also saved the staff a significant amount of work on that pt that can be directed toward other pts? The pt still must be worked to certain level to make sure he is fine but it is not at the same level as if we bring in an uncon/unresponsive person. Like it or not, we are the primary gatekeepers now (Only talking about higher volume Paramedic trucks right now).

This is a good discussion, lets keep it civil and professional.

FireMedAS
08-18-2006, 02:30 PM
If you're going to transport the patient anyway, then I think it's best not to use ammonia inhalants. I just don't feel that noxious wakening of a patient with altered LOC establishes anything meaningful. Most often, when I've seen them used (inside the hospital or outside the hospital), it's been a circus side-show act. "Let's make the faker wake up. Yuck, yuck." To me, this is not being a patient advocate. This is indulging our sick sense of humor. I personally do not believe that you can "make" a patient stop faking an illness. If a patient is being dramatic, or trying to impress their parents, or just got dumped by their boyfriend, or whatever, they are looking for sympathy and attention in a maladaptive way. But they are still human beings. To me this is analogous to a nurse using a large diameter NG/OG tube for an OD patient "to teach them a lesson." I'm philosophically opposed to any punitive medical procedures (and yes, I've seen the bilateral ammonia inhalant "tusks"). I just don't think it's necessary, I do not think there's any evidence to support the practice, and I think it violates the first rule of medicine. It's certainly no way to win your patient's confidence, particularly if they are not fakers, which from what I've seen represent a small percentage of the patients on the receiving end of this procedure. If it's such a good idea, then let's write a protocol for their use. I wish I could locate Dr. Bledsoe's article, because he makes the case much better than I do.


Whoa. I never said anything about signing the pt off after they woke up.

My question remains. What does a medical professional (no matter where they work or what they do) do to make a pt stop faking and for them to open thier eyes and eventually leave the hospital after they have been ruled out of other issues? Just a question that eventually has to be answered by someone in the treatment timeline.
We could just leave the pt alone, do the usual stuff for comas and transport but is that very efficient when it comes to cost containment and utilization review? We do try and work with the people at the hospital to make healthcare flow a bit better. If the pt is awake and talking clearly at time of delivery to the hopsital have we not now saved pretty big bucks in medicaid costs and also saved the staff a significant amount of work on that pt that can be directed toward other pts? The pt still must be worked to certain level to make sure he is fine but it is not at the same level as if we bring in an uncon/unresponsive person. Like it or not, we are the primary gatekeepers now (Only talking about higher volume Paramedic trucks right now).

This is a good discussion, lets keep it civil and professional.

leylandauto
08-18-2006, 03:15 PM
I am 100% behind you on adolescent behaviour. In my first post I wrote;

"There are those out there who may be adolescent over use them to 'punish' the person. Deal with the problem person do not limit the use of the tool."


You still do not ultimately answer my question. How do you (or the hospital)get them to stop faking? What is the proceedure?

FireMedAS
08-18-2006, 03:25 PM
You show them compassion and reason with them. If that doesn't work, you make sure they are stable, you rule out head trauma, you do blood work, and you observe them. That would be my preference. In my opinion, you have not established that ammonia inhalants prove that a patient is faking, particularly if drugs and alcohol are on board, which they so often are. It seems to me that you could easily fail to follow through on needed medical tests, and miss something critical, because you discounted the patient based on a response to ammonia inhalants. So in this era of evidence based medicine, I think it's fair to ask on what basis we triage patients with ammonia? The burden of proof is on you. Not me.


I am 100% behind you on adolescent behaviour. In my first post I wrote;

"There are those out there who may be adolescent over use them to 'punish' the person. Deal with the problem person do not limit the use of the tool."


You still do not ultimately answer my question. How do you (or the hospital)get them to stop faking? What is the proceedure?

leylandauto
08-18-2006, 03:49 PM
How many hours should the hospital bed be tied up? and do you really want to enable thier behaviour?
I am not stating that the ammonia should be the only test, just one of them if you have a strong suspicion that it is fake (especially common in the correctional area). Obviously it is not in my first line of evaluations but you always shape your medical approach to a pt based upon the available info presented to you (objective and subjective).
With any pt you need to do the required tests based on what you have in front of you.
I guess as far as triaging the pt when you get to the hospital, it would be based upon my presenting them with a CAOx4 Pt who was unconc with no pmhx and no evidence of ingestion. Heck, some of them will even admit to playing it so they could get out of Jail for a bit.
Ya still gotta do the proper medical assessment but it is a lot easier for the hospital now.
We have dealt many times with frequent flyers who fit this behaviour.
One mistake in medicine can ruin your career (along with the pt problem). You still have to practice medicine.

leylandauto
08-18-2006, 03:58 PM
Might just have to agree to disagree. :-)

FireMedAS
08-18-2006, 04:15 PM
Yeah, probably. LOL! :D

Here is the article, by the way. It turned up on Google.

www.bryanbledsoe.com/pdf/mags/Ammonia.pdf


Might just have to agree to disagree. :-)

Ltmdepas3280
08-18-2006, 06:55 PM
www.bryanbledsoe.com/pdf/mags/Ammonia.pdf

This is one persons opinion.....This one tool in your tool box...and you would never last in a high volume system....again its an opinion :rolleyes:

dmleblanc
08-18-2006, 08:21 PM
You still do not ultimately answer my question. How do you (or the hospital)get them to stop faking? What is the proceedure?


You show them compassion and reason with them.

Sometimes that's the best you can do. I remember a call a few years back in a truck stop/video poker place with an unresponsive female employee. Upon questioning bystanders, it was revealed that the patient had been arguing with a coworker when she suddenly "passed out". Suspecting a fake, one of our EMT's with some experience knelt down next to the patient and, holding her hand, whispered very quietly in her ear "I know what's going on here....we're going to move you to the back of the ambulance and then you're going to tell me what really happened....squeeze my hand if you understand". She squeezed, they moved her to the back of the ambulance where she had some privacy and everything was OK after that. I thought that was pretty interesting.

leylandauto
08-18-2006, 08:32 PM
Compassion and reason are also good tools :-)
it works more often than bravado and machismo.
It is good to have the biggest tool box you can get.

Weruj1
08-18-2006, 09:03 PM
FireMed ........we didnt show the pt anything .........it is another tool in the box and and as the post said it hasnt been used in long time. So you dont use them and we use them rarely, and thats OK.

montet202
08-21-2006, 09:22 AM
Firemedass...poor pt care and bad medicine is practiced when everytime a tool is used incorecxtly it is taken away. Train your people better and you will not have improfessional adolescents giving a pt tusks. Also: I don't know where you work, but I can't count the number of patients that tolerate a moderat sternal rub, the hand drop, NPA, etc.

With an uncon I determine why. Then I check for gag. I would much rather have ammonia waved under my nose than a toung depressor stuffed down my throat. Maybe if you worked with more professionals you would see and understand that tools like this can be used in a professional manner.

I have NEVER, in twelve years working in both very busy urban systems and slow rural ones, EVER treated my patients unprofessionaly. I have only used inhalents maybe once or twice. Got no pleasure out of it. But I am glad they are in my box. I will use them again if I find the need. And I will use them with the patient's best interest in mind.

firespec35
08-21-2006, 01:36 PM
Hey! That's a much better idea than not serving intoxicated patients! Good job! Do you hand them their car keys, too?
Not my job to serve them or not. I am not a bartender. I see them after that has already happened. Have you ever been in a nightclub with 3000 people in it. If I sent every person who passed out for a second to the hospital it would be outrageous. If I feel they need to, go they go. If they are not A&Ox3 when they wake up they go. If I don't send them out I make sure they have a ride home safely. I have personally waited with people till 0400 when I stop getting paid at 0230 because I did not want to leave them even though they are A&Ox3 and signed off.


I do not appreciate the smart *** comment. You don't know me. You Don't know what I do. Assuming... well you know the rest and I don't like my end of it. All I was trying to say is it is a tool in the tolbox when used wisely.

Engine58
08-22-2006, 01:37 PM
[QUOTE=montet202]Firemedass...poor pt care and bad medicine is practiced when everytime a tool is used incorecxtly it is taken away. Train your people better and you will not have improfessional adolescents giving a pt tusks. Also: I don't know where you work, but I can't count the number of patients that tolerate a moderat sternal rub, the hand drop, NPA, etc.
QUOTE]

EXACTLY!! In the area that I work in we cover a prison and alot of times the prisoners will fake a "seizure" or syncopal episode just to get out for the day...and we have a regular that always goes...You can do a sternal rub on him all you want...and he never moves...and before you say how do you know that he's faking... To me when you do the arm drop trick and his arm hits his face....then watch him and his one eye opens up..looks around at you then he starts "shaking" again... and ignores you...AFTER you tried reasoning and showing a little "compassion" he gets the ammonia inhalant..and what do you know..he wakes up and stays up for the trip to the ER once he wakes up I toss the inhalant in the trash. To me thats not misuse of an ammonia inhalant, now stuffing 2 of them up his nostrils and strapping a NRB to his face at 15lpm...now thats misuse and ridiculous :rolleyes:

croaker260
08-23-2006, 11:37 AM
OK, I am just catchingup on this thread...a little comment...


I have seen them used once or twice every year...I myself do not use them often (once or twice in 8 years maybe?). Usually I have a pretty good assessment skills to tell if a patient is status dramaticus if the sternal rub, a few quiet words wispered in the ear, or removal from the enabling bystanders doens work, they are getting a ride...so the use of the Ammonia is moot.


That said, of course there are those (even doctors) who misuse them. I too have seen "tusks", placed inside a NRB, and the other things described. I ahve also seen providers dick around on scene with an ammonia inhalent when they should have scooped and swooped to the rig.

Anyway I could ramble on and on ond simple repeat what other s have said, but I wanted to remind you of another risk of the amonia inhalent ... thatis it can significantly increase ICP with its use, like most noxious stimuli I would imagine, but I would imagine much worse due to the intensity.

food for thought.