Public Access Narcan

 

Medical emergencies, like cardiac arrest, anaphylaxis, heroin overdose, (and being bitten by a Black Widow spider), require quick treatment to save a life.   Our public health system recognizes this.  We have AEDs, epi-pens and now increasing access to Narcan. All great initiatives.  Before I advocate for public access anti-spider bite kits, let me address Public Access Narcan.

Public Access Defibrillators are put in spots where patients are more likely than others to suffer sudden cardiac arrest.  We see public access defibrillators in airports, casinos, health clubs and in town halls, outside the tax assessor's office.  Epi-pens are given to school nurses in case students with allergies to substances like peanuts have sudden anaphylaxis. These devices have been credited with saving many lives.  I wonder how effective or realistic a public access Narcan program would be. I would not put Narcan in health clubs or outside the tax assessor's office, but I might consider putting it in the bathrooms of establishments like fast food restaurants and laundromat in certain areas of town.  I have not yet responded to an overdose at a school, but there have no doubt been overdoses at schools, likely more than sudden cardiac arrests.  If they can have AEDs and epi-pens in schools, they surely have room for a dose or two of Narcan.  I would put Narcan there, and I would put Narcan by the clerk's desk at low-rate motels. I would put Narcan on city buses (done a few on these) , and in the gazebos of city parks. I'd even put one in the Zion Hill Cemetery based on the drug paraphernalia we saw when we drove through it one morning last week before the daily caretakers had swept the place.

I am very impressed that Massachusetts is able to record and report on the number of patients who receive Narcan from EMS responders. It likely wouldn't be too hard to track the zip codes and addresses of all the Narcan administrations.  Certain blocks could qualify for a Narcan alarm box on their street corner. Of course, you would need to configure the box so when activated, it would notify 911 to get EMS rolling. If the address was near a bar or nightclub, you could even consider putting Narcan in vending machines in bathrooms next to the condom or tampon machines.

In Connecticut Narcan is sold over the counter in pharmacies and often given away free at inner city clinics. But for those who frequent the night, maybe Narcan could be made available at grocery and convenience stores around the clock. They could sell it by the register or perhaps in another place people likely to deal with a heroin overdose might look, next to the ice machine.

I have never treated a patient bitten by a Black Widow spider, but I did treat a patient who used the powder that came in the pictured glassine bag.

The Finger

 I have been injured seriously enough to miss work twice in the last two decades.  Neither time was I injured on the job.  The first injury was playing softball on our ambulance team (back when we had one). I went from first to third on a single, and as the third base coach signaled me to slow, I stumbled coming into the bag, lost my balance, and landed on my outstretched hand, breaking a small bone in my wrist that required me to wear a cast for six weeks.  

A year or so earlier, I had broken the ring finger of my right hand at the top joint, playing basketball (going up for a rebound -- the ball hit the tip of my outstretched finger), but never had to miss work, as I was able to wear a splint that only immobilized the top joint, and enabled me to to still do IVs, lift and carry.  My finger is still slightly bent to this day.

I stopped playing basketball (for fear of injury) after that until a few years ago when our company, which does standbys at the Civic Center, organized a basketball game between divisions to be played on the Civic Center court (albeit before 12,000 empty seats).  I was enticed to join the team thanks to my height (6-8).  While I enjoyed myself and did quite well, largely thanks to hustle (I was running half marathons at the time and could easily out run most of the other players), I took a head butt to the chest in a scramble for a ball, that knocked the wind out of me.  I was able to keep playing, but it left me unable to sit up in bed at night without using a pillow to splint myself and it prevented me from doing push ups as I felt like my chest was going to split in two.  My diagnosis -- I think I cracked my sternum.  I never saw a doctor about it, but it was almost two months before I was pain free.  Still, I worked through it.  Never missing a day.

Recently I sustained another sports injury. I mainly swim now for competition, and in the last event of my last meet, I slammed my hand into the electronic pad at the finish (I had been upset that in two earlier races, the electronic pad had me slower than the hand timers who had clocked me in personal records.  So I hit the pad a little harder than I should have.  I did not feel any pain, but soon noticed the last joint of my middle finger flexed, but could not extend.  I had what is called a Mallet finger -- a ruptured tendon. My initial splint immobilized the entire finger, leaving me unable to work for two days until I saw a specialist who fashioned a splint enabling me to work, as long as I tape it up well. I can still do IVs and lift, but when I lift, I cannot use that finger which remains in a modified bird position.  I have to wear the splint for 6-12 weeks in hopes that the tendon will reattach.  If I move it too early, it is back to square one and another minimum of six weeks is required.  I have banged it a few times and had it squeezed twice in a wrestle with a patient, but for the most part I am hopeful it is healing. Surgery is an option, but the splint method actually has a higher cure rate that the surgery.

At work, we have a time clock where when punch in or out, you put in your Kronos number, and then place a designated finger tip on the scan button. When you first logged in to the new system, it let you choose which finger you wanted. Most people chose their middle finger. I thought about it, and while I appreciated the humor, I did not choose my middle finger.  I did the pointer finger instead.  And while I admit, there are days when I want to give the bird to work at the end of the day, I still maintain respect for the work.

When I was a kid, one of my favorite tales from the excellent American Folklore picture book I had was the story of Joe Magarac, the man of steel. Joe was the best worker in the steel mill.  He could do the work of twenty men. Then one day, there was talk of closing the mill, so Joe jumped into the vat and melted himself down into steel, and his steel was of such high quality that they built a new steel mill with his steel and everyone's job was saved and the town prospered.

I am not saying that we should all sacrifice ourselves for our companies (neither should we give them the finger).  If we do sacrifice ourselves, it should be for the idea of work and the idea that work and caring about your work has value.  Caring -- no matter what the object -- is what brings value to our lives.

Narcan Thoughts

 

A story on the news this week said the Hartford Fire Department has saved 136 lives with Narcan since they began carrying it last November.  They have used it 172 times with 136 positive results, according to the article.  (Kudos to an outstanding department!) The story also mentions the Connecticut State Police have saved 100 lives with Narcan since October 2014.  Google almost any fire or police department in the state who has started carrying Narcan and there are glowing reports of lives saved by their members.

Hartford Firefighters Save 135 from Opiate Overdoses

Connecticut had 415 heroin deaths in 2015, and over 600 fatal opiate overdoses of all types.  I have seen nothing to suggest that the number is declining in 2016.

Neighboring Massachusetts had 1,379 opiate overdose deaths in 2015, an increase of 7 percent over 2014.  According to MA state data,  Narcan was administered to 9,128 EMS patients in 2015.

Mass EMS Stats

The articles claiming lives saves to each administration of Narcan are a bit overblown.  Clearly not every patient administered Narcan by first responders would have otherwise died.  First responders do carry ambu-bags and paramedics are often only minutes behind.  Despite this, there is little doubt in my mind that first responder Narcan has been a successful program.

For all the high numbers of first responder administered Narcan in the Hartford area, paramedics and EMTs administer Narcan at even greater numbers than the first responders.  While the fire departments often beat us to the scene, it does take a few moments to access and assess a patient, and once we arrive, they defer to us.  I have on one occasion told them to go ahead and give their drawn up dose.  I have only once told a fire department (not Hartford) the Narcan they were getting ready to administer was not needed.  (The patient while altered was arousable with stimulation).  And I have yet to see and only rarely heard of a fire department inappropriately administering Narcan in our area.  I am thrilled the fear some had of inappropriate administration doesn’t appear to have come to fruition.  

I will be curious to see what the final fatal opiate overdose numbers will be for Connecticut in 2016.  I suspect they will be higher than 2015 despite the life-saving  first responder Narcan program  such is the rate of overdose we are seeing.  Sure, we had periods of increased overdoses due to bad batches of the drug hitting the street in the past, but nothing sustained like we are seeing with the current epidemic.  Narcan alone cannot put an end to the slaughter.  On the fatal overdoses I respond to, the patient has almost always overdosed alone and has been found far too late to be saved.

Last week, I observed a heroin addict prepare to shoot another up in an alleyway just off Park Street as I walked past with my just out of the bakery hot-pressed Cubano sandwich.  My height enabled me to better see what others might not have.  I hesitated.  The one with the USB cord wrapped around his arm saw me and told the other to hold up.  I felt like I had stumbled onto a tribal ceremony.  The man with the syringe, seeing my uniform, said, “No worries.  He's EMS.  We are safe with him here.  Yo,” he called to me.  “Thank you for what you do.”

“Okay, okay,” the other man said, holding his shaking arm out.  Just give it to me.”

“You have Narcan?” I asked, somewhat stunned by the scene, their brazenness and my sudden inclusion in their moment.

“Yeah, man.”

“All right, Be safe,” I said, and resumed walking to my parked ambulance just down the street.  Later, I almost wished I had asked if I could observe out of curiosity, but lines are lines, and while impartial, I did not want to imply sanction.

My partner and I did a walk by later and found the alley empty, except for a spoon, a saline vial, and torn heroin bag wrappers.

If I had any advice to people doing heroin (aside from don’t get started), it would be don’t do it alone.  Have Narcan handy.  Don't wait to call 911.  Never give up on treatment.

OMG

 

Two weeks ago, it was Black Jack. This week it is OMG. Oh, My G**.

The woman lays on a parking lot sidewalk behind the school. Her face is blue and she is only breathing one or two times a minute. She is wearing tight spandex and bright pink tank top. She has tattoos on both arms.  I am guessing she is in her thirties. Our response is routine. A shake to see if we can get her respiratory rate up.  It increases to 6. She briefly opens her eyes, then goes back out. We lift her up and put her on the stretcher, and get her into the back of the ambulance. Her ETCO2 is 70. Without stimulation, her breathing is agonal. We give her 0.25 of Narcan IN up each nare (We continue to experiment with dosing. How little can we give and still get the response we need.).  My partner puts in an IV and we take out a 100 cc bag of saline that we put 0.5 mg of Narcan in. By the time she has received 20 cc (0.1 mg) her ETCO2 is down to 35 and her eyes open on prodding.  We shut the drip off.

She wants to know what happened. We tell her where we found her. She doesn't live in the neighborhood, but it not unfamiliar with it.  She admits sniffing some heroin. She says she doesn't do it often. She finds it hard to believe she was barely breathing.  I ask her how she got started, and she says it was just around and she used it with others. She says she isn't a true addict. I ask her what markings were on the bag she bought.  She says there was green on it, but she can't recall what it was called.  She just wanted some. Fair enough. She thanks us for helping her. She says she will be more careful. You can never tell what is in the heroin anyway and one slip and you are dead. We get her in her ED room. I am making the stretcher up when the nurse calls me back in the room. The patient wants to know again where she was when we found her. I tell her and she thanks me again. She is very polite, very grateful. She thanks us for saving her life.

Later, the nurse tells us our "lovely patient" left AMA after stealing half a tray of IV supplies.

My partner and I have identified a number of spots in the city where people are known to shoot up. We go early in the morning and do a census of the wrappers. I feel like an archaeologist as we record the names and numbers of each. We find Comptons-- a minimalist bag with the word Compton stamped in red on it. We found some of these last week, but no quite so abundant as we are now finding).  We find a new one called Emerald City-- a colorful green and black preprinted bag. But far and away the freshest most plentiful bags are OMG, Oh MY G**, another multicolored bag.  We find only a few Black Jacks and they appear old. Fleeting Glory.

Two days later we get a call for an unconscious in a car. Based on the address, we are pretty sure it will be another heroin OD. It is in a parking lot on a street I have done many OD s on.  The customers buy the drugs off Park Street, and then find a place to shoot up before they get back to the suburbs -- at least those who can't wait do. The Fire Department is banging on the car door.  The man inside looks at them, but seems to be in a bit of a stupor. There is a lot of shouting. They open the door. You're not in trouble, we just need to check you out, my partner says. You're crazy sweaty. A young man in a bright white t-shirt with a thin cut Mohawk is finally persuaded to step out, but then he suddenly makes a move back inside to grab something -- a syringe. There is a short wrestling match and shouting.  The man is thrown up against the car.  A police officer retrieves the one cc syringe. It has .5 cc of a water with a ribbon of blood in it. The needle is bent. I dispose of the syringe while my partner gets the man on the stretcher. He is trembling and very diaphoretic. On each arm is a tattoo of a dragon. With the police officer, I do a quick look in the car for additional information. We find ten empty heroin bags in the console.  A bundle. All OMG.

Our patient is tachycardic at 140. He says he has not used in four days. His pupils are pinpoint. Sweat is beaded on his forehead. He is bleeding slightly from a vein in his hand. I am guessing he nodded off halfway through his hit with the syringe still in his hand vein. He didn't get enough to get rid of the sickness. He won't get Narcan from us, even though he nods off at times during the transport. We give him fluid and Zofran. He tells us he hurt his shoulder lifting weights and was put on Percocet. He got hooked. He has been to rehab several times. He tells me he called a beeper number, and then met his contact by the bakery on Park (There are several bakeries on Park). He too is grateful to us. He tells us how thankful he is for us helping him. He says he wants to get back into rehab.

He shakes our hands at the hospital once we him to his ED room. I write on a piece of paper the address where his car is parked. My partner gets him a pillow for his head.

Later that afternoon we are driving down Park Street. I do a double take. I see a familiar young man in a white tee-shirt standing in a doorway of a boarded up store, talking on a cellphone. He has a distinctive Mohawk and tattoos on this forearms.

OMG.

***

 

Black Jack

I did three heroin ODs on one shift last week. Another medic did four in a shift the day before. Lots of OD calls going out. All three of these ODs used the same brand. Black Jack. For years, dealers in the Northeast have been branding their supply, stamping or printing it on the glassine envelopes the heroin is sold in. While many areas of the country get their heroin in small balloons made from the tips of latex gloves or torn off shopping bags, in Hartford (which is supplied from the New York I-95 route) it is almost always sold in the small glassine bags. One bag $5. A bundle of ten bags - $50. Black Jack is evidently pretty strong as there seems to be a big demand for it, and it is knocking people down. The more deadly, the greater the appeal. That is why many of the brands promote the idea of danger.

Big dealers take a kilo of heroin and cut it down, mixing it 50/50 with baking soda. It is enough to fill 25,000 glassine envelopes, which are usually prestamped with the brand, before being distributed along the chain.

I have heard that dealers make the first batch extra strong to create a demand, and then slowly cut its strength. When I was in medic school there was brand on the streets called Tango and Cash, named after the Sylvester Stallone/Kurt Russell movie cop duo. It was laced with Fentanyl and caused enough death and furor on the Hartford streets to earn mention in the New York Times.

Toxic Heroin Has Killed 12, Officials Say

Lacing heroin with Fentanyl seems to en vogue again, as it is mentioned in most articles that deal with upswings in ODs. On one scene, a bystander noted that the heroin must have had Fentanyl in it as his buddy was an experienced user, and was not normally felled by such a small amount.

One of the overdoses was a woman who does a $100 dollars worth of heroin a day. Two bundles. She Oded in the bathroom of a doctor's office where she had brought her mother for an appointment. They were able to wake her with stimulation, though she would nod back off if you left her alone. She decided to clean out her pocketbook while we checked her out. She tossed a crack pipe and several empty Black Jack envelopes, one of which she gave to me. She wore a skimpy top for such a large woman. She had numerous tattoos on her arms. Her pocketbook was filled with condoms. She told me she had gotten into heroin five years ago when she found out her boyfriend was cheating on her. She was very sad she said and wanted escape.

Looking at the Black Jack stamping on the envelope, I had an idea to collect empty heroin bags as a sort of an urban art collection. I thought of all the brand names I had heard over the years. Atom Bomb. 9/11. Empire. New World. Isis. Obama Care. I could drive around Hartford, attempting not to buy heroin, but the empty bags. No, no, I don't want the heroin, please pour it out, or sniff it yourself, I just want the empty bag. Gotta any Monkey Man? No, I don't need 357, I have that one. I Goggled the topic and found I had been beaten to the punch. Graham MacIndoe, an ex-junkie included photos of heroin bags in All In, Buying In to the Drug Trade, his memoir of addiction. Then there is Dequincey Jynxie ( a pseudonym), who at one point had a collection of over 3,000 bags before she threw them out. For awhile, she was the go to expert on heroin bag labeling. She even ran a web site Jynxie's Natural Habitat where she had posted photographs of various branded bags and rated them them in three categories, Rush (Strength of Drug) Legs (How Long it Lasts) and Count (How much You get for the Price).

I went to the blog, and looked at the stamps and read some of the reviews. Here is what a reader wrote about Ace of Hearts.

'Best product I have come across in the neighborhood in a while! This connect was formerly slingin' something called Public Enemy #1 for some time which wasn't terrible, but this is far superior. No name or letter on the bag, just an image of an Ace of Hearts (which I suspect is preprinted (ie not stamped). A bit pricey at $100/bun, but a very consistent product nonetheless."

When I went to the blog site, the first thing that caught my eye was an entry titled The Future of Jynxie.

As many of you have already guessed, I've decided it is no longer feasible to continue this blog. This is because with Jynxies death I am permanently logged out of the main administrative account, meaning I can only post myself, can't invite authors, and can't change the format or administer this blog in the way it needs to keep it running smoothly.

The post was by Eve, who often co-posted with Jynxie, and had taken over maintenance of the blog as Jynxie went through recovery and tried to move on to something different in her life. I assumed Jynxie must have died of an overdose, but with a little more digging I found out she did not die of a heroin overdose, but had left the market several months before and moved to Oklahoma to work in her boyfriend's family business. There, she and her boyfriend were murdered, and their house set on fire with their bodies in it in an as yet unsolved homicide. It also turns out she was an IVY League graduate and artist, who had once had her work displayed at the Museum of Modern Art. She was also a designer for Old Navy.

Check out some of these names listed on her blog: DOA, Just Do it with the Nike label, Jim Jones.Little Debbie, Versaci, True Blood, America's Most Wanted, Double Dragon, Dark Night, Walking Dead, Level 9, Overdose, Godzilla, Rihanna, Dead End, Zombie, Four of a Kind, BioShock, Life Support, Powerball, Medusa, OMG, Lights Out, 007, Kill Bill, Breaking Bad, 24K, Got Milk?, Lacoste Knockout, Ace of Hearts, Happy Hour, Red Butterfly, Hell Boy, Toy Story, Oblivion, War Horse, Venom, Bring A Friend, No Parking, 9mm, Bada Bing.

I read a recent article on the net about how drug dealers in Philadelphia put NBA MVP Stephen Curry's picture on their heroin bags. If you were a sports memorabilia collector, how much would you pay for Kobe Bryant's first NBA basketball card? How much would you pay for a limited edition empty heroin bag with his picture on it?

Philadelphia drug dealers stamping image of NBA star Steph Curry on heroin bags

When the actor Phillip Seymour Hoffman was found dead, there were empty glassine envelopes near his body stamped with the Ace of Hearts and Ace of Spades. Intrepid reporters found Jynxie's Heroin blog and reported on the reviews for the batch, which I mentioned above.

The woman who gave me the empty Black Jack bag, nodded off again in the ambulance. We put an ETCO2 cannula on her and watched her ETCO2 slowly rise to the 70s. We ended up giving her 0.02 Narcan IV. Yes, 0.02, not 0.2. The deal with Narcan is you only want to give enough to keep them from hypoventilating, but not necessarily wake them up. That is often a hard line to walk. Often if you wake them up with vigorous stimulation, they will fall back asleep and once asleep, they start hypoventilating. This woman was very nice and did not want to upset her dose at the same time, I did not want her to hypoventilate, and I knew while I could keep her roused all the way to the hospital, I would likely get tired of constantly hitting her in the triage line to keep her breathing nor would I feel comfortable leaving her in a room to fall back into hypoventilation once we left her. The 0.02 Narcan given as two 0.01 pushed five minutes apart seemed to do the trick. I delivered it by putting 0.1 mg in a 10 cc flush. Next time I think I will put 1 mg in a 100 cc bag and just run a slow as needed drip. This is the type of dosing that is traditionally used in hospitals for patients who hypoventilate post sedation.

The other two Black Jack patients that day were both men. One in his 40's who had a new heart valve(within the last month) and said he was just using for the first time again after his operation and this was just as a one-time deal. We hear that alot. Before we got to him, his buddy gave him the city's home remedy, ice in the pants. He needed IN Narcan from us as his respirations were 1-2 a minute. Again, we experimented. Giving 0.5 mg in each nare with a plan to wait five minutes while bagging before giving him the rest. This is the Maine guideline. It worked great and he was breathing and talking to us in about four minutes with no signs of withdrawal. He agreed to come with us to the hospital. While on scene, I made sure to teach his friend how to do IN Narcan, and he promised he would go down to the health clinic and get one of the kits they handed out. What about the ice in the pants? he asked. You don't need to do that, I said. Just give Narcan. Okay, he said, I'm going to go down there this afternoon.

The last victim drove his car into a parked car, and was so out of it, the police had to break the window out with a window punch to pull him out of the car. He was pale as can be when we got there, but talking. We got him in the ambulance and he said he did not want to go to the hospital. He wanted to drive home. We explained his car was totaled but he did not believe us. He was in his twenties. The cop came over and gave him a stern lecture on how the streets would eat up a skinny white kid like him from the suburbs. He told the cop this was the first time he had used heroin. On the way to the hospital, he admitted to us, he had been using for ten years. He started recreationally using stolen pain pills from his friend's parents when he was 15. We didn't have to give him narcan, but we talked to him about the drug. He said he carried a Narcan kit in his glove compartment.

I have a set of questions I ask all heroin users (if they will answer. Post Narcan patients tend to be very quiet and withdrawn). How did they get started? How many times have they been to rehab? Do they have Narcan handy or do their friends and families? I think now I will start asking them what their top five brands of heroin are of all-time?

Just playing around, if I was a heroin distributor, here are some of the brands I might think about starting:

OJ, Ebola, Double-Barrell, Roulette, 911,Tombstone, Smackdown. Zika, DNR.

Yesterday, during a downtime between calls, my partners and I decided we would drive to a park near drug area and see if we could find any empty bags with labels on them. Here's what we found in a little over 15 minutes of looking along the edge of the parking lot:

Black Jack, Call of Duty, Focus, Adidas, El Chapo, Worldstar, Chief, Headphones(just a design), Compton, Avengers, Money Bags, Avatar. We also found one with a weird red design and a few that were indistinguishable. Only Black Jack was multi-colored, several had fancy designs, others just a stamped name. It had rained hard that morning, so the bags were damp and some muddy. There were also lots of unlabeled bags. We found some that were colored pink, others light blue. In some cases we found the same brand clustered together. I don't know how long the bags had been there, some -- the clustered ones were likely fresh (an addict does a quick bundle and tosses the wrappers out the car window). Some of the others could have been there for months. It was hard to go two feet without finding an empty bag of one kind or another. Some people hunt Pokemon. We hunted empty heroin bags.

Later we drove by a few other areas and within moments found more brands, including Louis Vitton.

But everywhere we went we found Black Jack.

My Addiction, Through My Eyes Self-portraits by Graham MacIndoe.

RIP Jynxies Natural Habitat

The Hidden Story of Middle-Class Heroin in Brooklyn and Beyond

Shelby Hughes Obituary