Introduction: We report a case of accelerated idioventricular rhythm (AIVR) identified by Emergency Medical Services (EMS) monitoring of an infant presenting with lethargy and respiratory distress. Accelerated idioventricular rhythms are rare ventricular rhythms originating from the His-Purkinje system or ventricular myocytes, consisting of >3 monomorphic beats with gradual onset and termination.(1) An AIVR is usually well-tolerated and does not require treatment, though sustained arrythmia may induce syncope, and the rhythm has been seen in newborn infants with congenital heart diseases.(1) Monitoring ill children with ECG can identify such dysrhythmias in the prehospital setting. Case Report: An 18-month-old male presented to their pediatrician with lethargy and respiratory distress, prompting activation of EMS. The patient was placed on a 4-lead ECG initially revealing monomorphic QRS complexes at a rate of 170 beats per minute (BPM). A 12-lead ECG was interpreted as sinus tachycardia by the paramedics who noted the QRS complexes were "getting taller and shorter" with a stable rapid heart rate. The clinician then noted a consistently wide tachycardia which spontaneously converted to a narrow complex tachycardia. The QRS pattern remained variable, with notation of variable R-wave height. After arrival to the emergency department, pediatric cardiology was consulted and interpreted the prehospital ECG findings as accelerated idioventricular rhythm. The patient experienced multiple occurrences of accelerated idioventricular rhythm during hospitalization without associated hypoxia or decreased perfusion. Discussion: Accelerated idioventricular rhythm is relatively rare entity without underlying cardiac disease and most cases are asymptomatic or benign. In the pediatric population, AIVR is generally related to congenital heart defects, cardiac tumors, and cardiomyopathies. In the prehospital setting, continuous ECG monitoring should be a part of care by Advanced Life Support personnel in children with altered mental status, respiratory distress, unexplained syncope, or suspected arrhythmias and 12 lead ECG should be considered if there is any abnormality noted. While this patient did not experience persisting morbidity from AIVR, the potentially hazardous rhythm would not have been recognized without the astute observation, clinical management and persistent follow up of the prehospital clinicians.

In 2021, an 8 -mg intranasal naloxone product was approved by the Food and Drug Administration; however, no studies have examined outcomes among persons who receive the 8 -mg naloxone product and those who receive the usual 4 -mg product. During March 2022-August 2023, New York State Department of Health (NYSDOH) supplied some New York State Police (NYSP) troops with 8 -mg intranasal naloxone; other troops continued to receive 4 -mg intranasal naloxone to treat suspected opioid overdose. NYSP submitted detailed reports to NYSDOH when naloxone was administered. No significant differences were observed in survival, mean number of naloxone doses administered, prevalence of most postnaloxone signs and symptoms, postnaloxone anger or combativeness, or hospital transport refusal among 4 -mg and 8 -mg intranasal naloxone recipients; however, persons who received the 8 -mg intranasal naloxone product had 2.51 times the risk for opioid withdrawal signs and symptoms, including vomiting, than did those who received the 4 -mg intranasal naloxone product (95% CI = 1.51-4.18). This initial study suggests no benefits to law enforcement administration of higher-dose naloxone were identified; more research is needed to guide public health agencies in considering whether 8 -mg intranasal naloxone confers additional benefits for community organizations.

This article refers to:Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications

Jones et al. demonstrate that through hard work and thoughtful review, even disparate data can assist the advancement of public health and public policy across jurisdictions. An emergency medical services industry-led focus on documentation standards and data integration can make this easier and more effective for our patients. Jones et al. have taken on the challenging task of identifying the characteristics of opioid-related incidents (ORI) from emergency medical services (EMS) calls to assess the impact of opioids in Massachusetts. They responded to a legislative mandate to review EMS records by creating a free text search and a five-tier severity cascade where opioid use can be identified, even without overdoses [1]. These researchers demonstrate the need to review all available data despite the fact that Massachusetts [2], like much of the United States, utilizes multiple EMS documentation platforms, written in disparate documentation styles, then aggregated through the National EMS Information System (NEMSIS) [3]. Authors have focused previously upon the use of naloxone to identify a non-fatal overdose [4-6], but many ORI do not receive naloxone [7]. Jones et al. used a free text search for terms in the narrative to point to specific types of ORI. This search function was elegantly designed to go beyond the discrete variables of NEMSIS and search for ORI by intoxicant name and concerning symptoms. Jones et al. have previously demonstrated gender disparity with EMS naloxone administration, indicating why it is vital to use narrative data to identify ORI [8]. The strength of this search and the ORI severity cascade is further demonstrated, as 29% of the opioid intoxications and 36% of all ORI did not receive naloxone. The OTHER ORI allows a broad range of conditions that can factor into the impact of opioid use disorder and serve as a further marker for opportunity for intervention and change. EMS records are the first chapter of the story of nearly every critical patient encounter and assist in the care of vulnerable patients. However, when hospital systems implement an electronic health record they frequently save money by not integrating local EMS data. When embedded in the health-care continuum, EMS data can help to advance public health and public policy. Jones et al.'s multi-tiered approach to ORI is an important step towards realizing this goal. Michael Winter Dailey: Writing—original draft (lead); writing—review and editing (equal). Emma Furlano: Writing—original draft (supporting); writing—review and editing (equal).

BackgroundPeople experiencing homelessness may use emergency medical services to access health care. We sought to examine the relationship between homelessness and prehospital evaluation and treatment of chest pain.MethodsWe obtained 2019 data of all emergency medical services activations from a single 9-1-1 provider in San Francisco, California with a clinician's primary impression of chest pain. Using chart review, we categorized patients as experiencing homelessness or not and determined treatment rates between the two groups based on local chest pain/acute coronary syndrome protocol. We then stratified the two groups based on primary impression subcategories: "chest pain-not cardiac" and "chest-pain-cardiac/STEMI"; ST elevation myocardial infarction (STEMI).ResultsA total of 601 chest pain calls were analyzed after excluding non-transports and pediatric patients. 120 incidents (20%) involved patients experiencing homelessness. Across all chest pain impressions, people experiencing homelessness were less likely to receive aspirin (35% vs 53%; p < 0.001), intravenous access (38% vs 62%; p < 0.001), and nitroglycerin (21% vs 39%; p < 0.001). No patients experiencing homelessness received analgesic medication, though only 4% of other patients received this intervention (0% vs 4%; p = 0.020). People experiencing homelessness were more likely to receive a clinical impression of "chest pain-not cardiac" compared to "chest pain-cardiac/STEMI" (68% vs 32%; p < 0.001). Results were less significant in most fields when adjusted for impression sub categorizations: "chest pain-not cardiac" versus "chest pain-cardiac/STEMI." Greater than 97% of all patients received 12 lead electrocardiograms.ConclusionsSignificant disparities were observed between patients experiencing and not experiencing homelessness in the prehospital treatment of chest pain. Larger scale evaluations are needed to further assess potential disparities in care for people experiencing homelessness in the prehospital setting. Using prehospital clinician impression as a proxy for acuity may mask existing bias and disparity; however, 12-lead ECG acquisition, the key diagnostic tool, was appropriately performed in more than 97% of all chest pain patients.

Background The COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the hands of key responders, including law enforcement officers who are often first on the scene of a suspected overdose, is one such strategy. New York State (NYS) was one of the first states to implement a statewide law enforcement naloxone administration program. This article provides an overview of the law enforcement administration of naloxone in NYS between 2015 and 2020 and highlights key characteristics of over 9000 opioid overdose reversal events. Methods Data in naloxone usage report forms completed by police officers were compiled and analyzed. Data included 9133 naloxone administration reports by 5835 unique officers located in 60 counties across NYS. Descriptive statistics were used to examine attributes of the aided individuals, including differences between fatal and non-fatal incidents. Additional descriptive analyses were conducted for incidents in which law enforcement officers arrived first at the scene of suspected overdose. Comparisons were made to examine year-over-year trends in administration as naloxone formulations were changed. Quantitative analysis was supplemented by content analysis of officers’ notes ( n = 2192). Results In 85.9% of cases, law enforcement officers arrived at the scene of a suspected overdose prior to emergency medical services (EMS) personnel. These officers assessed the likelihood of an opioid overdose having occurred based on the aided person’s breathing status and other information obtained on the scene. They administered an average of 2 doses of naloxone to aided individuals. In 36.8% of cases, they reported additional administration of naloxone by other responders including EMS, fire departments, and laypersons. Data indicated the aided survived the suspected overdose in 87.4% of cases. Conclusions With appropriate training, law enforcement personnel were able to recognize opioid overdoses and prevent fatalities by administering naloxone and carrying out time-sensitive medical interventions. These officers provided life-saving services to aided individuals alongside other responders including EMS, fire departments, and bystanders. Further expansion of law enforcement naloxone administration nationally and internationally could help decrease opioid overdose mortality.

Our previous studies using an Induction-Delay-Expression (IND-DEL-EXP) paradigm to study hypertensive response sensitization (HTRS) demonstrated that various challenges (stressors) including a subpressor dose of angiotensin (ANG) II given during IND, resulted in HTRS to a subsequent treatment with slow-pressor dose of ANG II during EXP. The induction of HTRS is associated with upregulated expression of proinflammatory cytokines and the macrophage marker CD11b in the brain regions involved in blood pressure (BP) regulation including the lamina terminalis (LT) and paraventricular hypothalamic nucleus (PVN). In this study, we investigated whether brain macrophages are necessary for low-dose ANG II-induced HTRS. Depletion of brain macrophages was produced by feeding a colony-stimulating factor 1 receptor (CSF1-R) inhibitor, PLX3397 (75 mg/kg/d), beginning 1 week before starting IND and continuing the drug throughout the 1 week IND period. The results showed that in control condition, low-dose ANG II (10 ng/kg/min) treatment during IND resulted in an enhanced hypertensive response to the subsequent slow-pressor dose of ANG II (120 ng/kg/min) when compared to control animals with saline pretreatment during IND (Δ39.1±4.2 vs. Δ21.5±4.9 mmHg). Depletion of brain macrophages during IND slightly increased baseline BP, which came back after stopping feeding PLX3397 during DEL. However, the depletion of macrophages blocked HTRS induced by low-dose ANG II given during IND (Δ25.8±4.3 mmHg). Immunohistochemistry confirmed the depletion of macrophages in the subfornical organ and PVN after feeding PLX3397. The results indicate that brain macrophages are necessary for the induction of HTRS.

Anaphylaxis is a life-threatening condition with a known effective prehospital intervention: parenteral epinephrine. The National Association of EMS Physicians (NAEMSP) advocates for emergency medical services (EMS) providers to be allowed to carry and administer epinephrine. Some states constrain epinephrine administration by basic life support (BLS) providers to administration using epinephrine auto-injectors (EAIs), but the cost and supply of EAIs limits the ability of some EMS agencies to provide epinephrine for anaphylaxis. This literature review and consensus report describes the extant literature and the practical and policy issues related to non-EAI administration of epinephrine for anaphylaxis, and serves as a supplementary resource document for the revised NAEMSP position statement on the use of epinephrine in the out-of-hospital treatment of anaphylaxis, complementing (but not replacing) prior resource documents. The report concludes that there is some evidence that intramuscular injection of epinephrine drawn up from a vial or ampule by appropriately trained EMS providers—without limitation to specific certification levels—is safe, facilitates timely treatment of patients, and reduces costs.

Introduction: Acute patella dislocations account for up to 3% of all knee injuries. Prehospital care of patella dislocation often includes knee immobilization and pain management, but in the wilderness environment patella reductions are often performed by basic life support providers. Given the potential benefits of early reduction, the perceived low risk of harm and precedent with which the procedure can be performed, patella reduction was added to the EMT scope of practice in New York State. Our objective is to characterize the mechanism of patella related injuries and describe the success rate and complications experienced with the addition of a prehospital patella reduction protocol.Methods: This was a retrospective review of a voluntary, preexisting, quality assurance database of cases in which a patella reduction was attempted between October 1, 2016 and June 30, 2018.Results: 90 patients underwent an attempt at patella reduction at one of 52 EMS agencies during the study period. The most common mechanism was a sports-related injury. Patella reduction was successful 83/90 (92.2%). Median pain score was reduced from 10 to 2. There were no reported complications.Conclusion: While a convenience sample, our results provide preliminary evidence that patella reduction can be performed by EMS providers with infrequent complication and offers significant pain relief.

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.

For most terminally ill patients, the preferred place of death is home. Previous literature has demonstrated the feasibility of at-home terminal extubation performed by critical care and hospice physicians. This case report describes a terminal extubation performed by a paramedic under the direct supervision of an Emergency Medical Services physician in the patient's home. Guided by a comprehensive plan and logistical support from a team of hospice providers, a successful out-of-hospital terminal extubation is possible. To truly achieve patient-centered care at end of life, the choice for an out-of-hospital death is necessary.

Objective: Naloxone is an opioid receptor antagonist that reverses life-threatening effects of opioid overdose. Since the 1970s, naloxone products have been developed as injectable solutions, and more recently as nasal sprays. Naloxone products have saved many lives in emergency settings. These products are routinely carried by public safety first-responders including fire fighters (FF), law enforcement officers (LEO), and emergency medical services (EMS). Now, they are also distributed through community access programs to the public. While public safety medications are monitored, those publically distributed are not, so expired products can be possibly found on-hand in an emergency. This study analyzed the quality and stability of expired Naloxone HCl Solutions for Injection, to assess their remaining efficacies and potential risks. Methods: The samples were collected from EMS or law enforcement training supplies and expired returns, with expiration dates ranging from 1990 to 2018. Using standardized techniques, the remaining naloxone was quantified, and the main degradation products, nornaloxone (also known as noroxymorphone) and other possible species, were monitored and quantified systematically. Results: Most tested samples were found containing more than 90% of labeled naloxone, including those stored for nearly 30 years. The naloxone degradation was slow, but generally correlated with storage time length. There was no significant amount of degradation products detected across all samples. Nornaloxone was detected from some older samples, but all less than 1%. Therefore, although it is an opioid agonist, the risk caused by nornaloxone should be low. Conclusion: This quality assessment demonstrates that expired naloxone products may still meet USP standards, even after many years. Further pharmaceutical, clinical, and regulatory investigation should be conducted to confirm our findings, especially for new naloxone products with different formulations and routes of administration. Extending the shelf-life of naloxone products may have important financial and public health consequences in addressing future drug shortages and meeting the needs for this critical drug.

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.

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.

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.

Journal of Palliative MedicineVol. 19, No. 9 Letters to the EditorEnd-of-Life Care: Whose Decision Is It Anyway? A Case Study in an Assisted Living FacilityDavid N. Hornick, Christopher Paynter, Michael W. Dailey, and Yuchi YoungDavid N. HornickHomedical Associates, Schenectady, New York.Search for more papers by this author, Christopher PaynterDepartment of Health Policy, Management and Behavior, School of Public Health, State University of New York (SUNY), Albany, New York.Search for more papers by this author, Michael W. DaileyDivision of Prehospital and Operational Medicine, Department of Emergency Medicine, Albany Medical College, Albany, New York.Search for more papers by this author, and Yuchi YoungDepartment of Health Policy, Management and Behavior, School of Public Health, State University of New York (SUNY), Albany, New York.Search for more papers by this authorPublished Online:1 Sep 2016https://doi.org/10.1089/jpm.2016.0159AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"End-of-Life Care: Whose Decision Is It Anyway? A Case Study in an Assisted Living Facility." Journal of Palliative Medicine, 19(9), p. 904FiguresReferencesRelatedDetails Volume 19Issue 9Sep 2016 InformationCopyright 2016, Mary Ann Liebert, Inc.To cite this article:David N. Hornick, Christopher Paynter, Michael W. Dailey, and Yuchi Young.End-of-Life Care: Whose Decision Is It Anyway? A Case Study in an Assisted Living Facility.Journal of Palliative Medicine.Sep 2016.904-904.http://doi.org/10.1089/jpm.2016.0159Published in Volume: 19 Issue 9: September 1, 2016Online Ahead of Print:June 6, 2016PDF download

Abstract Background: EMS providers frequently encounter opioid-toxic patients who receive naloxone and then refuse further medical care. Older studies revealed this practice to be safe. In light of the evolving patterns of opioid abuse, this study attempted to determine the safety of this practice. Methods: This is a retrospective review of all patient encounters by the Los Angeles Fire Department (LAFD) between July 1, 2011–December 31, 2013. All LAFD patient encounters are stored electronically. These electronic records were reviewed for subjects who received naloxone had a documented respiratory rate (RR) less than 12, and subsequently refused transport. Data abstracted included name, social security number (SSN), date of birth (DOB), date of EMS encounter, age, and treatment rendered. The names, SSN, and DOB, as available, were supplied to the coroner's office. The Coroner's records were reviewed to determine if a patient with the same or similar name (e.g., Jon vs. Jonathan) had died within 24 hours, 30 days, or 6 months of the initial EMS encounter. The abstractor was blinded to the study hypothesis. Results: 205 subjects were identified; the median (IQR) age was 41 (29-53) years. 27 (13%) were female. One subject (0.49%) died within 24 hours of the initial EMS encounter. The cause of death (COD) was coronary artery disease and heroin use. Two additional subjects (1. %) died within 30 days. One of these subjects died 6 days later; the COD is unknown. The other subject died 20 days after the EMS encounter; the COD was cardiovascular disease and liver cirrhosis. No additional subjects were identified at the 6 month follow up. A third subject died of a heroin overdose 16 months after the initial EMS encounter, but was beyond the pre-defined follow up period. Conclusions: The practice of receiving pre-hospital naloxone by paramedics and subsequently refusing care is associated with an extremely low short- and intermediate-term mortality. Despite an evolving pattern of opioid abuse, the results of this study are consistent with previously reported studies.

In the commentary by Strang et al., ‘Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures?’, published online 3 February 2016, Dr Strang and his co-authors argue that providers who utilize an off-label intranasal (i.n.) device to increase access to naloxone are acting unethically and dangerously. We disagree strongly, as the lead author himself stated in a previous publication: ‘These studies are vital, but they must not delay implementation. While we dither, people continue to die from overdose’ 1. Off-label use of medications is a legal, justified and common practice in many countries, including the United States and United Kingdom 2, 3. Off-label prescribing permits practitioners to respond nimbly to emerging or individualized patient needs not served adequately by existing products or formulations. Providers in many countries realized more than a decade ago that needles were obstructing naloxone access for many populations, from parents with addicted children to prisoners at release. The need for broader access to naloxone in the time of a raging public health crisis is a perfect example of a situation in which off-label prescribing can and should provide a safety valve 4. Nasal naloxone was trialed formally by emergency medical services (EMS) in Denver in 2002, and adopted by other EMS agencies because of its efficacy and safety 5. The first bystander naloxone program to use nasal naloxone was in Boston, where providing injectable naloxone to laypersons was deemed unacceptable and nasal naloxone had been the EMS standard of care for years 6, 7. This program has been associated with reduced overdose mortality 8. As of 2013, 37.5% of organizations in the United States that distribute naloxone reported providing intranasal only; an additional 11.8% provide both i.n. and intranasally (i.m.) 9. The authors’ statement that ‘…the failure of effect of i.n. naloxone, for whatever reason, can delay the time to naloxone injection until an ambulance arrives’, ignores the fact that if no naloxone at all is available—as is the case in many places that have delayed naloxone access—administration would also be delayed until the ambulance arrived. Moreover, further development of nasal and other formulations, such as the lead author's patent for buccal naloxone, may never have happened without the pressure of grassroots efforts. We think it important to draw readers’ attention to the authors’ disclosure of involvement in the development of both a nasal and a buccal naloxone, and believe that this needs to be considered when Dr Strang and his colleagues state unequivocally: ‘clinicians should prescribe take-home naloxone only as one of its licensed formulations’. apparently supporting products in which they have an interest. P.C. has led studies of naloxone access funded by U.S. federal agencies. Unrelated to this paper, P.C. has led investigations involving use of ledipasvir/sofosbuvir donated from Gilead and naltrexone (not naloxone) donated from Alkermes, and J.R. owns stock in Alkermes. M.D. is engaged in ongoing volunteer medical advisement and oversight to the New York State Department of Health law enforcement naloxone program that uses intranasal naloxone. M.D. is a recipient of a $20 000 NYS DoH grant to create law enforcement training for opioid overdose response that used intranasal naloxone. M.D. has served as an unpaid expert witness. S.S. and L.B. are involved in ongoing paid and volunteer efforts to increase access to naloxone, including nasal naloxone.

Introduction: Utilization of extracorporeal membrane oxygenation (ECMO) in OHCA (E-CPR) is increasing. This therapy can extend the therapeutic window to correct the etiology of OHCA by reperfusing vital organs, but its success is extremely time-sensitive. By definition, an E-CPR candidate must be in reasonable proximity to necessary resources. It is unknown how much of the US population resides within geographic areas that have access to E-CPR. Purpose: Estimate the US population that could reasonably access hospitals capable of E-CPR. Methods: We geocoded ECMO centers in the lower 48 states that participate in the Extracorporeal Life Support Organization (ELSO) and plotted 45-min drive time isochrones calculated with coordinated average drive speed around each hospital, representing the distance that could be reasonably covered by ground EMS transporting a cardiac arrest patient. We selected 45 min to maximize the geographic catchment area with a best case scenario of rapid candidate identification and E-CPR deployment (evidence-based convention of maximum collapse-to-ECPR interval is Results: A total of 104,359,381 persons reside within the 45-min isochrone areas (37.3% of US population). Extrapolating the annual incidence of OHCA, 131,910 OHCA cases/year occur within feasible EMS drive time of an ECMO/E-CPR center, and 221,483 OHCA cases/year do not. Conclusion: One third of the US population resides within a feasible distance for EMS ground transport to an E-CPR capable hospital. Prehospital cardiac arrest protocols should be locally tailored to this consideration. More widespread ECMO use or alternative E-CPR deployment strategies may expand the availability of this therapy.