Today’s episode of the podcast is a myth busting on all the media reports about first responders overdosing by being exposed to fentanyl in the field by incidental contact. This is physically impossible and the misinformation out there has scared a lot of people, cost us lots of money in the form of hazmat responses and shutting down hospitals, and prevented overdose patients from getting the timely care they need in an emergency. This episode will systematically go through every argument why fentanyl is NOT harmful via incidental exposure and debunk these myths to give first responders one less thing to worry about while they do their frequently dangerous yet vital work.

Podcast link

The ACMT Statement on Incidental Fentanyl Exposure

OMG…he put fentanyl and carfentanil on his bare hand and look what happened…NOTHING!

This police officer “had his life saved” with narcan in this dramatic body camera footage…the substance was later found to be methamphetamine…

Below is the script of the podcast edited into the form of a blog post in case you are interested in reading it instead of listening to the podcast. Please spread this far and wide and share it with anyone who is concerned about incidental exposure to fentanyl being a concern for first responders.

DISCLAIMER: I’m not doing this episode to discredit those in law enforcement, the fire service, EMS, or any other first responders.  I was an EMT-B in southeastern Pennsylvania for 10 years before starting my emergency medicine residency so I know how tough your jobs are on a daily basis. First responders face danger every day and they don’t know when or where it’s coming from.  My goal with this is to bust some of the myths out there so that you can be safe but also give you one less thing to worry about.

First- Listen to the Experts- The American College of Medical Toxicology

If you want to read what the experts on this topic have to say, the best place to look is the position statement by the American College of Medical Toxicology. Here’s the link to their statement.  I’ll be referencing this policy statement frequently and it’s worth a read as it succinctly and accurately presents all the information on this topic with evidence- not hysteria.

What is “Incidental Exposure”?

When I say incidental exposures, I am talking about common scenarios that first responders would be exposed to such as brushing it off of a uniform or being in the room with fentanyl- even if someone throws it up into a big cloud. To put these incidental exposures into context, we will talking about extreme examples of exposures and showing that, even in these extreme examples, the ability to be exposed to an amount of fentanyl enough to cause an overdose is just not possible.  

Incidental Inhalation Exposure

Let’s talk about the first concern- that you can be exposed to a significant amount of fentanyl by inhaling it during an incidental exposure.  This can’t happen.  Due to it’s chemical properties and vapor pressure, powdered fentanyl cannot be absorbed through the air.  The particles are too big to result in exposure via breathing it in via incidental exposure to the power.  One of the frequent points of confusion is that if you google for fentanyl inhalation, you come across a CDC website that talks about this topic and what precautions you should take. However, in the first sentence of that page it explicitly states that this page is only about using fentanyl in a terrorist situation where it has been weaponized.

Weaponization is a process where the particles of fentanyl are ground finely enough that they can be inhaled.  No street level fentanyl is being weaponized because it is an expensive, dangerous, and unnecessary process.  The only documented case of fentanyl being weaponized was during the Moscow Theatre hostage crisis in 2002 where the Russian government pumped what is suspected to be weaponzied carfentanil and remifentanyl into a theatre where there were hostages being held in an attempt to subdue the hostage takers. 

Yes, people died from opioid exposure from the weaponized fentanyl analogues but the key here was that it was weaponized- not regular fentanyl found in the drug supply.  Let’s go back to that weaponizing process- its complicated, expensive, and unnecessary for street level heroin.  You don’t need to weaponize fentanyl in order for it to be absorbed via the intravenous route or by snorting it.  Snorting or smoking heroin with fentanyl results in prolonged contact of a large amount of fentanyl via a mucous membrane or by heating it- not the incidental exposure we are talking about where some gets on your skin or even your eyes where you aren’t intentionally ingesting it.

In factories where liquid fentanyl is made for healthcare purposes and some may be aerosolized in the air as part of the process, workers do wear respiratory protection with masks, gloves and gowns.  However, even if you went into one of these factories completely unprotected, it would take 200 minutes or almost 3.5 hours for someone to absorb 100 micrograms of fentanyl through inhalation exposure.  100 micrograms of fentanyl is a common therapeutic dose for an adult patient when given relatively quickly as an IV push- not exposed over multiple hours. 100 micrograms is not enough to cause an overdose in an adult.  So incidental exposure to aerosolized fentanyl or the drug being thrown up in the air is just not an issue.

Incidental Skin Exposure

So what about absorbing it through the skin?  Don’t we have fentanyl patches that allow this to happen?  Fentanyl can be absorbed through the only when you are talking about fentanyl patches because there is specific technology in a fentanyl patch to allow slow absorption through the skin.  Without this special formulation and patch technology, you cannot absorb a significant amount of fentanyl through the skin.  Even if you were to try to overdose on fentanyl patches this is next to impossible.  In a study cited in the ACMT position paper (page 2), if you covered the entire surface of both your palms with many fentanyl patches and let them sit there for 14 minutes, you would only absorb 100 micrograms of fentanyl or- once again- a therapeutic dose for the average sized adult- nothing even close to being able to cause an overdose.  

So fentanyl being brushed on the skin momentarily or even sitting there is not a way you can be significantly exposed or overdose. To prove that point, here’s a video of a opioid activist who recorded himself putting powdered fentanyl and carfentanil on his bare skin and letting it sit there.  Guess what happened- nothing- no overdose, his body didn’t “shut down” or anything. This also a person who previously had issues with opioid addiction so ask yourself- would someone risk their long term sobriety of seven years by putting this on his skin if he thought there was any chance of it causing an exposure?

Also, healthcare professionals use IV fentanyl in liquid form everyday in hospitals across the world. Do you know what happens when a vial breaks or if we get it splashed on our skin?  Nothing happens, no one dies and no one needs naloxone.  We just clean it up.

Logically- why would you inject it if you could get high from putting it on your skin???

If skin exposure from fentanyl was possible, why would anyone have to inject it to get high?  Why would you go through the pain of injection or risk serious infections like endocarditis, abscesses, or necrotizing fasciitis or risk exposure to HIV and hepatitis from sharing needles?  One response to this is that those who are addicted to opioids have built up a tolerance so they won’t show any effects from skin or inhalational exposure but as we have just shown that is not possible.  Also, let’s say you started by injecting fentanyl, wouldn’t you then want to switch over to skin absorption if that was at all possible?

Carfentanil = Fentanyl (in regards to skin and inhalation exposure)

Carfentanil is a synthetic opioid similar to fentanyl but more potent microgram per microgram. It was found in a drug supply a few years ago and I think it caused this hysteria to be born but I’ll talk about that in a minute. Because of the increased potency of carfentanil, it is not used in humans and it is only used in veterinary medicine to sedate very large animals like moose that weigh several tons. Everything I am saying about skin and inhalation exposure to fentanyl applies to carfentanil as well.  It is no different from fentanyl in regards to its inability to be absorbed through the skin and through inhalation.  

The only information we have on human exposure to carfenatnil is from a single case report of a veterinarian who accidentally splashed some carfenatnil into his eye.  He felt tired and then a few minutes later loaded himself up with naltrexone which is a long acting version of naloxone.  However, the fact that he only felt a little tired after being exposed to carfentail into his eye refutes this concept that incidental exposure to skin or even mucous membranes to fentanyl can cause immediate respiratory depression and unconsciousness or your “body to shut down”

Logic Part 2…Fentanyl has been in the drug supply since…1976!

Even if you are skeptical of the science, let’s acknowledge a single indisputable fact that fentanyl in the drug supply is nothing new- it has been there for decades.  China white is heroin mixed with a fentanyl derivative that was first reported in 1976.  1976. Where was the concern about skin and inhalation exposure to fentanyl back then?  The answer is that it didn’t exist- this is a totally recent phenomenon. 

From my own experience, I ran EMS a lot in the early 2000s.  Around 2001 I specifically remember that we went from carrying 2mg of naloxone in our kits to 10mg because we started seeing a resurgence of heroin laced with fentanyl in the southeastern Pennsylvania area.  Did we do anything different before or after in regards to protecting ourselves from incidental exposure?  Nope- nothing changed- no hazmat suits, we didn’t carry naloxone to protect ourselves, nothing like that.

My theory on how this hysteria started

I think it started after the first reports of carfentanil in the drug supply. I think this, along with the rising opioid crisis, scared the crap out of people.  When people saw these ridiculous pictures of the tiny speck of carfentail that could cause death in humans if it was injected I think it really scared people. Then there was a lay media report of a cop in Connecticut who claimed to brush some powder off his uniform then suddenly felt “my body shutting down” he felt lightheaded and dizzy and those by him claimed he lost consciousness. 

However, none of these symptoms point to an opioid exposure. People who are having an opoioid overdose will have respiratory depression, small pupils, and unconsciousness. Instead, what this cop likely experienced was a psychosomatic reaction or perhaps the nocebo effect.  The nocebo effect is the opposite of the placebo effect. The nocebo effect is where a person’s mind causes them to be ill as a result of an inert substance or intervention instead of them feeling better like in the placebo effect.  The cop believed that he was exposed to fentanyl and believed that this would harm him and his body took over from there.  There was never any testing to confirm that he was actually exposed to fentanyl. Here’s an article from Tonic where a person who helps opioid addicts test their heroin for fentanyl. He has frequently had heroin with fentanyl and carfentanil on his skin and has always tested negative on urine drug screens.

So what is the explanation for these videos of cops being exposed and needing narcan?

These are not fentanyl or other opioid exposures- they are panic reactions.  They are panicking because we have done this to ourselves by scaring the crap out of people. In these videos you see conscious and alert people asking for naloxone.  If you can ask someone to give you naloxone or if you can administer it to yourself, you don’t need it.  

One story from Texas was where flyers espousing conspiracy theories were found on the windshields of cop cars.  The flyers said they had been laced with powdered fentanyl.  A cop started driving and felt lightheaded so she drove herself to the ED where she was given naloxone as a precaution.  If you can drive yourself to the ED you were not exposed to and significant amount of fentanyl or any opioid.  Period, end of story. In a not so shocking development, it turns out that when the flyers were tested, they showed no trace of fentanyl.

I will go one step further- if a first responder claims that they were incidentally exposed to fentanyl and they end up with a positive opioid test, they are likely using the excuse of incidental exposure to cover up for their own illicit use of opioids.  Yet all these stories are breathlessly reported by the media to represent the dangers of incidental fentanyl contact and add to this growing narrative that this is a real danger to first responders when it is not.

But better safe than sorry, right? Not really…

Finally, what if you say “Doc, I get it, the risk is low, but better safe than sorry, right?”  The answer here is no- it’s not better safe than sorry because it will cause people harm in the long run by being hesitant to treat overdose victims.  We have already seen cases of treatment delayed due to concerns about being in the same room as fentanyl and this can’t happen.  Even if you aren’t wearing gloves, you can confidently provide emergency treatment to a person experiencing an opioid overdose. 

Additionally, can we also acknowledge the millions of dollars wasted on these huge hazmat responses and shutting down hospitals and prisons over concern for fentanyl exposure?  Police departments are wasting money on fentanyl detectors and I have even seen nitrile gloves marketed as fentanyl safe and being sold for a premium.  This is misleading advertising because any nitrile glove will protect you from fentanyl- as will your skin- you don’t need to spend extra money on a special kind of nitrile glove.

In Summary: Incidental Exposure to Fentanyl isn’t a thing and if you think it is after reading this then you’re basically an anti-vaxxer or flat earther…

So to sum this up- skin and inhalation exposure to fentanyl from incidental contact is not a thing. It was never a thing and it never will be a thing.  At this point if you still believe it’s possible I don’t know what to tell you and you’re pretty much going the route of anti-vaxxers and flat earthers in not believe the science and logic.  So if you work in the medical field or law enforcement go about your day with one less thing to worry about because incidental exposure to fentanyl or carfentanil is not something your need to be concerned with.

Final Summary:

-Skin absorption: You cannot absorb fentanyl found in the drug supply on the street via incidental contact through exposure on your skin or by breathing it in. Transdermal fentanyl patches do exist that allow skin absorption but it’s a special formulation that doesn’t apply to powdered fentanyl

-Inhalation exposure: This can only happen if it is weaponzied which is an expensive and dangerous process that no street level dealer is doing because its unnecessary. Yes you can snort fentanyl and overdose on it but that is not the kind of exposure we are talking about here. We are talking about non-intentional and incidental exposure from being around fentanyl- even if it is thrown up in the air.

-Carfentanil– Everything said about fentanyl applies to carfentanil as well. While carfentanil is more potent microgram per microgram, it is not absorbed any differently from fentanyl

-Even if you don’t believe science, believe logic: If you are addicted to opioids, wouldn’t you rather absorb fentanyl from your skin rather than snort it or inject it? Also, fentanyl has been in the drug supply for decades. This is nothing new and for decades we didn’t have any problems with incidental exposure and didn’t change what we did.  The reason why I think there is hysteria is due to finding carfentanil in the drug supply.

I am happy to discuss this further in the comments but FAIR WARNING– I’m not going to entertain any trolling on this topic that doesn’t present any honest questions or doesn’t present actual peer reviewed evidence to the contrary. I’m also not interested in hearing stories saying “some guy I knew almost died from being exposed to fentanyl on a call when he touched it” and insisting that it happened and that I’m wrong.

EM Basic is finally back with a new episode. Today’s episode will discuss neonatal resuscitation with Dr. Azif Safarulla, a neonatologist at Augusta University. Dr. Dan McCollum and Dr. Jessica Gancar interview Dr. Safarulla on the nuts and bolts of running a successful neonatal resuscitation in the ED. These can be one of the scariest populations we have in the ED so it’s important to have a rational and logical approach to quickly assess and intervene on our smallest and youngest patient population.

Neonatal Resuscitation

Hello everyone,

EM Basic will be back soon with new episodes but I am writing this post to bring your attention to the new 2018 Surviving Sepsis guidelines…and why I (and many others) think that they have to go.

Here’s the bottom line and the real sticking point: the 2018 Surviving Sepsis guidelines mandate antibiotics and 30 ml/kg fluid bolus now be given within 60 minutes of emergency department TRIAGE!?!?  This has zero evidence behind it and will only cause patient harm by rushing to implement antibiotics and fluids that most patients will not need.  Does anyone remember the “antibiotics within 4 hours of pneumonia diagnosis” debacle?

You learned from the sepsis update on this podcast that the goal of sepsis care (as stated by Scott Weingart from EmCrit) is that you don’t have to do a lot of crap, you just have to give a crap.  This means tailoring your interventions to what the patient needs- not a blind following of a rigid protocol or guidelines.  This tailored approach is supported by multiple multi-center international RCTs and it is what we should be doing in the ED for our patients with sepsis.

Josh Farkas and the EmCrit crew have spearheaded a petition to call for a retraction of the 2018 surviving sepsis guidelines and you should definitely read their take on this at the EmCrit page.  These guidelines were started with the best of intentions but have lost their way by mandating therapies that most patients won’t need.

If you want to contribute, go to the petition website and add your name to the list of those who think that the 2018 Surviving Sepsis guidelines should be retracted.

Until next time…

Steve

Just a few days after the new EM interns start, today’s episode will talk about my advice to new EM interns.  Think of this as the “big picture advice” or a 30,000 foot view of how to approach EM residency.  I’ll talk about 4 major big picture points to keep in mind as you start your residency.  This will go way beyond “arrive early, stay late, and always keep learning” and expand on some big picture ideas of how to function well as a new intern.

Big Picture Advice to New Interns Podcast

Below is a blog post version of the podcast in case you want to read it (edited for clarity):

4 Big Picture Pieces of Advice to New EM Interns

#1 EM residency is a 3 or 4 year exercise in figuring out what your attendings want. The earlier you accept this, the better and more productive you will be as a resident.

Every attending will have a different way of doing things. This can seem enormously frustrating at first because it may seem like you are getting so many different messages.  Think of this way- You are a single learner working with many different attendings.  Each attending has their own knowledge base, risk tolerance, and ways of doing things.  On the flip side, I am a single attending working with many different learners.  Each learner has a different fund of knowledge, a different way of thinking about things, and a different way in which they learn best.  As an attending, I wouldn’t expect every learner to be exactly the same- at the same time, as a learner you can’t expect every attending to practice the same way.

Instead of getting frustrated by what may be seen as many mixed messages, figure out a respectful way of asking your attending why they are doing it this way as compared to what you have seen other attendings do.  For example, you could say something such as “I’ve seen other attendings approach this differently” and explain what you have seen.  Anyone who works with residents or students should not take offense to this but rather should take this as an opportunity to acknowledge that there is practice variation and teach their thinking on this topic.

The best attendings will acknowledge upfront when they teach something that they know has wide practice variation.  One final way of looking at this is that residency is the opportunity to see many different styles of practice and mold your own practice, taking the best parts of each attending that you work with.

#2 Attendings teach what they know

When you first start off, the knowledge base of your attendings can seen overwhelming.  I found myself thinking “There is no way I will be able to know what they know when I graduate from residency in 3 years (or 4 years PRN)- it’s just too much to know!”  This can be frustrating and intimidating but I’m going to let you in on a little secret- attendings teach what they know.

Everyone has their own subset of knowledge that they are really great at so they will likely teach that frequently.  For example, if you’re on shift with me and we start talking about airway then you should get comfortable because we could be there for a while because I am a huge airway nerd.  However, if you ask about which toxic alcohols cause which lab abnormalities, yeah- I’m gonna need a minute and probably an up to date consult- but the next attending you work with may be really into tox and know that off the top of their head.  You can substitute airway and tox for critical care, ultrasound, sports medicine, pediatrics, and the list goes on and on.

Trust me there are attendings out there- the renaissance women and men, if you will- that truly know just about everything there is to know.  That’s its own skillset the same way people are experts in all the other topics and just about all of these attendings have more than a little gray hair.  So don’t get frustrated if it seems like the knowledge base in EM is endless and impossible.  Trust me that you will learn what you need to know during your residency and you will develop an area of mini-expertise if you work at it.

#3 When presenting a patient, you should rarely ask your attending how they would manage the patient without giving your own plan first.

My next piece of advice has to deal with moving on from the reporter stage to the manager stage.  As an early medical student, the expectation is that you can report your findings accurately.  As a more senior medical student and intern, we want you to move beyond this reporter stage and into the manager stage.  We need to know that you have thought through a plan on how you want to manage the patient.  As an intern, that plan does not have to be 100% correct- you just need to have a plan.

For example, let’s say you have a young female with chest pain and shortness of breath.  The not as good way of giving your assessment and plan would be “This is a 20 year old female with chest pain and shortness of breath. Should we scan her for pulmonary embolism?”

The much better way of presenting this would be “This is a 20 year old female with chest pain and shortness of breath.  I don’t think I would scan her for PE because she has no risk factors for PE and normal vital signs”.  This is a much better way of presenting this because it has shown that you have made a gestalt assessment of the patient and what their plan should be instead of just reporting what you found.

If you present it the first way, you haven’t made a management decision yet.  If you present it the second way, we can have a conversation about Well’s and PERC criteria and ways of risk stratifying patients for PE and tie it into your own gestalt assessment.  So if you ask an attending a management question such as “would you get a CT for PE on this patient” don’t be offended or think the attending is lazy when they say “What would you like to do”.  This is our way of forcing you to think through the patient management plan and committing to it which is a vital skill to learn in EM.

As an attending, my number 1 job is to keep patients safe so I won’t let you do anything unsafe.  That is your permission to make that management decision when you present the patient.  If I don’t think it’s the right plan, I’ll tell you so and teach why I think a different plan would be better.  As a resident, you will be wrong sometimes and that’s ok- you are learning and remember what I said about practice variation between different attendings.  So resist the temptation to ask your attending what you should do in regards to a management decision without first making the call yourself.

#4 Residency is a long 3 (or 4) years but it is finite and your life will get better as an attending.

Residency is fun sometimes and it’s hard a lot of times.  You are going to work a lot.  When you start as an intern everything is new and exciting and you should hold onto that feeling for as long as humanely possible.

However, somewhere around the middle of your first year, maybe sometime in your second year after a few intense rotations in a row you’ll probably get a little frustrated.  You’ll probably think to yourself “this sucks and its never going to end, I’m going to work this hard for the rest of my life”.  I am here to tell you that this is not true.  Yes, you will work hard during residency and the hours will be long but trust me, it does get better- much better.

As an EM attending, the only reason you would work as many hours as you did as a resident is because, for some insane reason, you choose to.  I don’t think you would get much argument from EM attendings when I say that if your attending job has you working as much as your residency hours, you should find a new job.  Your life as an attending will get better.  You will have multiple days off in a row without having to give up one of your kidneys or work 15 days straight.  So called “golden weekends” in residency will just become “weekends”.  Sure, you’ll have to work weekends, nights, and holidays but having a full weekend off will not become a rare luxury any more.

Don’t get me wrong- you will work hard as an attending but your work life balance will be much, much better than it is in residency. You will have more time off and fewer demands on your time. So keep this in mind when the hours are long and seem like they are endless- I assure you that life gets better.

Finally, if you are feeling burned out or are having a tough time, please seek out support from your residency director or someone you can talk to in your residency program. We are all there to help and we are there to support you. We do not want anyone to feel like they are doing this alone. There have been far too many suicides in medical residents and we want them to stop. So please take care of yourself and seek out support if you are struggling.

Today’s episode is on the evaluation and management of sickle cell anemia in the Emergency Department. Dr Jared Walker, a third year EM resident at the University of Florida Jacksonville, has written and recorded this excellent review of sickle cell disease. This episode will discuss how to properly assess patients with sickle cell, how to order the right labs and imaging, what red flags to look out for, how to control sickle cell pain, how to catch the various complications of sickle cell, and proper patient disposition.

Sickle Cell Anemia Podcast

Sickle Cell Disease Show Notes (Word Format)

Sickle Cell Disease Show Notes (PDF)

Check out our bandwidth sponsor, EB medicine. They several issues on sickle cell disease in both kids and adults- check them out here.  Residents can get free access to all their great resources by going to the ebmedicine EM Basic page and attendings can get a discount on their products that offer CME.