Monday, September 21, 2020

Connecticut EMS Opioid Overdose Data

 In Connecticut, when EMS responds to an opioid overdose, after they have taken the patient to the hospital, accepted a refusal, or presumed a patient dead, they are required to contact the state poison control center and answer a series of questions about the overdose.

The program, known as SWORD (Statewide Opioid Reporting Directive), that went statewide on June 1, 2019, recently released the results of its first year of data collecting.

Here are the highlights:

There were 4,505 suspected overdoses including 337 fatal overdoses, reported by EMS to the SWORD program between June 1, 2019 and May 31, 2020.

Males accounted for 74% of the overdoses; females 26%.

People between the ages of 25 and 39 were most likely to overdose.

When the drug of exposure was known, 87% of the overdoses were due to heroin or fentanyl versus 11% for prescription opioid and 2% for methadone or suboxone.

Bystanders gave naloxone in 15% of the overdose cases where 911 was called.

88% of overdose victims were transported to the hospital.

2% of overdose incidents involved multiple patients.

11% of overdoses occurred in motor vehicles.

There were 131 “spike alerts” generated. 

109 public health and public safety agencies are registered in Connecticut to view the data.

The full report can be found here:

SWORD ANNUAL REPORT

For more information on the program, check here:

Connecticut SWORD Program

Here’s a video explaining how the program works:






Sunday, September 20, 2020

Heartbeat

 Labor day weekend I had an irregular heartbeat.  I had a funny feeling in my chest and when I took my pulse, son of a gun, I was missing a beat every now and then.  I wasn’t near any place where I could put myself on the monitor and see what was actually going on, but every time I checked, even when I wasn’t feeling anything, i couldn’t get to 30 without a dropped beat.

I am sixty-two years old, and while I feel I have been in somewhat of a physical decline over the last two years, particularly this last year with the COVID altering my normal workout eating and mental health routines, I have never questioned the strength or health of my heart before.  I admit that it scared me.

I tried to determine what might be causing the missed beat and focused on two culprits.  A medication I take for my thyroid which can cause palpitations and caffeine.  I did- against my better interests have several coca-colas that day of and the day before.  I am somewhat addicted to Coke, but often go months without it because it makes me cough quite badly when i do drink it.  Still I love the taste in a glass with lots of ice cubes and I just sip it.  I particularly enjoyed the flavored varieties.  Coke with lime, first among them.  It is hard for me not to relapse.

So I cut out the caffeine, even the green tea that has been my sad replacement for Coke.  I also stopped my other medication for two days.  I resumed that med, but kept off the Coke, and after a few days, not only could I go a sixty count without a missed beat, every time I checked I was at a perfect 60.

This post originated as I stood in the cafeteria looking at the fountain Coke machine that lets you add whatever flavor you want.  I was really close to getting one, and I thought I would write about how despite my irregular heartbeat, I still couldn’t kick the habit.  But will power prevailed and I still haven’t had a Coke (Shh-there was an old 20 ounce bottle of Cherry Coke on my desk with maybe 3 ounces left in it.  I filled a Dixie cup up with ice and poured a couple sips worth into it, and I did this a couple, three times till I was holding the bottle over my head and trying to shake the last drops out before tossing the bottle into the trash, never to have Coke again. Ha!).  We need to be stronger as we grow older.

When you start out as a medic you are usually of the age where you feel an invincibility about your life.  You know that someday you may end up like your patients but it is so far off you don’t need to worry about it.

My hand on my neck, I count sixty steady beats.

I don’t want to think about the future, but I know it's out there.

***

Judge Ruth Bader Ginsburg died two days ago at 87.

May we all use the remaining time we have left on this earth in the service of our families, fellow humans, country and world.

Peace to all.

Friday, September 18, 2020

Nalmefene

 I heard today that Opiant, the company behind the 4 mg Narcan Intranasal spray, is at work on a new product to combat opioid overdose -- Intranasal Nalmefene.

Nalmefene Nasal Spray

Nalmefene is an FDA approved medication to reverse opioid overdoses when used intravenously. It has yet to be approved in a nasal form suitable for first responders and laypeople.

The company cites the more rapid onset and longer lasting properties of Nalmefene as a better (stronger, longer acting) drug to combat “longer-lived synthetics.”

The theories behind IN Nalmefene are as follows:

It may be needed to battle stronger synthetic opioids.
It lasts longer than naloxone.
It works faster.

I have some questions about the need for a longer acting drug. Heroin lasts longer than fentanyl. I get this both from the pharmacology of morphine versus fentanyl, but from conversations from street users who tell me heroin lasts for them 6-8 hours versus 3-4 hours for fentanyl. Keep in mind that the effects go down rapidly from their peak so that by the end of these time periods, users who are addicted are starting to feel sick and are beginning withdrawal. Maybe there are other synthetics that last longer, but I am unaware of them.

While in EMS we often tell people that naloxone doesn’t last as long as heroin. I hear people saying naloxone only lasts 30 minutes. (Its half life is 1-2 hours.) There is a fear that the naloxone resuscitated person will go back into overdose when the naloxone wears off. I have yet to see a person go from alert and talking post resuscitation to suddenly apneic again at the stroke of 30 minutes. Depending on the dose and route of naloxone, especially if titrated carefully, I have had patients who needed a bit more. The second wave overdose is more a concern with long acting opioids such as time-released pills or methadone, not so much with street heroin or fentanyl. Many studies have shown that most heroin users are safe to release from care if they are alert and have good oxygen saturations post naloxone.

For an excellent discussion of the safety and literature behind naloxone refusals read this article from ems1.com.

The post-naloxone patient: Optimizing opioid overdose refusals

I am also not certain that we need a stronger drug than naloxone. While there is much talk and anecdote about fentanyl requiring more doses than heroin, I have not really found this to be true. (And I have done hundreds of fentanyl resuscitations).  It can be a self-fulfilling prophecy where medics hear that fentanyl requires more so they give more without waiting patiently for the first dose to take effect. I know of cases of people getting huge doses, but on inquiry, the timing between doses was not well spaced. Are you waiting five minutes between doses while you bag and are you seeing signs of improvement--increasing respiratory rate and decreasing ETCO2?   I have yet to hear of an opioid that does not respond to naloxone.

What does appeal to me about Nalmefene is the claim that it works quicker than naloxone. That I think would be great when used by lay people or single responders who lack the ability to effectively use bag-valve mask ventilation. Lay people often come upon overdosed patients who are not breathing. Without the ability to ventilate them, a quicker acting drug would clearly be life-saving. I have often been on scenes were patients have received three, four and five rapid fire doses from laypeople, who basically empty all the Narcan they can find into a person hoping to get them breathing again. 16 mg in one minute is not unheard of when the laypeople have four autoinjecters at hand.

We of course are left with a combative, vomiting patient once we arrive. This is better than finding someone apneic, but still hard to deal with.

I continue to be against the use of the Narcan 4 mg IN for EMS providers who respond as more than a single responder because of its increased likelihood of side effects when the standard of care is for EMS providers to titrate with the smallest possible dose while they use bag valve mask ventilation.  Vomiting and agitation are common in patient put into withdrawl by the 4 mg IN dose, which is equivalent to 2 mg IM.  Paramedics should start with no more than 0.4 mgs as a first dose.  i know many medics who start with 0.1 IV and add 0.1 each minute until respirations are stored.  Many times their patients don't even realize they have been given naloxone the effect is so gentle.

It is my understanding that IN Nalmefene is still at least two years away from approval/distribution, and needs additional study.

Fighting Fire with Fire: Development of Intranasal Nalmefene to Treat Synthetic Opioid Overdose

Shock Index

 I attended a CME recently where I heard a term I had never heard before.

SHOCK INDEX

The shock index (SI) is heart rate divided by systolic blood pressure. The normal range is 0.5 to 0.7.

The shock index has been shown to be a predictor of increased likelihood of shock, hospital admission, and mortality.

Someone is likely at risk for shock if their SI is over 0.8.

If my systolic blood pressure is 120 and my heart rate is 60, my SI is 0.5.
If my systolic is 120 and my heart rate is 120, my SI is 1.0 --in the danger zone.

While most paramedics can just look at a patient and tell you whether or not they are in shock, the shock index can help raise concern for someone in who is at risk for decompensation.

Here's some studies on the shock index.

A prehospital shock index for trauma correlates with measures of hospital resource use and mortality

Shock index in patients with traumatic solid organ injury as a predictor of massive blood transfusion protocol activation

Here’s a great article on shock.

Approach to Shock

 

Wednesday, September 16, 2020

Back in the Water

 

This week the local aquatics center opened for the first time since the COVID scare locked the state down back in late March.  I have already swum twice and have lanes reserved nearly every day of the week ahead.

I missed the pool terribly when it was closed.  The water has always been my buffer between the world and my home.  I finish a long shift at work, I stop at the pool and plunge into the cool water and all of the city comes off.  By the time I get home, I am relaxed, feel great and am totally into chilling with the family. 

With the pool closed, I suffered.  I suffered physically and mentally.  My physical conditioning declined.  I was irritable.  I slept poorly.  I felt older, stiff and slower moving.  I hurt my back a year ago and have occasional numbness in my legs that worsened.  My diet went out of whack.  I felt stressed all the time.

I used to walk over to the aquatics center and look in the center’s back windows where I would see the pool, still filled with water, but the lights darkened.  Why did they have to close it down? I asked the night sky? 

I support all the people who have taken the often unpopular decisions to shut down society while we tried to get a handle on the epidemic and keep people, particularly our elderly, safe. 

Still I railed at individual decisions that affected me.  Why take the hoops down from the basketball courts that my daughter and I used to shoot at when there was never anyone else playing?  Why shut down sixth grade basketball playoffs held in a giant gym attended by maybe thirty people in a space that could accommodate a couple thousand?  Why close my pool, my beloved pool, that when I went there at 8 at night, usually offered my choice of multiple empty lanes?  Some nights when the high school swimmers weren’t practicing I was the only one there in the 11 lane pool.

Couldn’t they have instituted the procedures they have now to keep it open?  Wear a mask into the building, maintain social distancing, you are required to reserve your lane.  Everyone leaves the pool at 50 minutes after the hour and the next group comes in at the top of the hour.  Twice a day the pool is closed briefly for cleaning.  Limited people in the building.  No showers.

When I swam last night, in the lane next to me was a man who I have seen there for years.  Instead of swimming he walks back and forth in the water.  He is a large man and moves slowly, but he rarely misses a night.  After his walk and my swim, we would often sit with others in the large spa (hot tub/Jacuzzi) and pass small talk or just nod good evening.  The spa is closed still for more obvious reasons.

I wonder what this man did all those nights when the pool was closed.  Another man who used to swim every night discovered walking and I would often see him out walking with his wife.  I hope it helped.  I wonder about all the others who used to swim as often I did.  How did they make out these past hard months?

I write all this not to whine about what has passed or to celebrate what has opened.  I write it to reflect on all the ways the epidemic has injured us.  Many have suffered grievous losses.  (Far more than my minor complaints). Some have lost lives, lost health, lost work, lost joy.  It isn’t over yet, and there will still likely be more hardships ahead, but we should be kind to each other, and we should all work for safe ways to find our way back to what we lost.  I am ever so thankful I can swim again.

Stay safe everyone.