The Opioid Refusal

 The Opiate Refusal

Called for ETOH.  On arrival found 28 year old male slumped on park bench, GCS-3, respiratory rate -4, cyanotic around lips.  Does not respond to stimulation.  Given 2 mg Narcan IN by FD just prior to our arrival, ventilated with ambu-bag using two person method.  Initial ETCO2-94.  Sinus at 88.  BP 130/70.  No signs of trauma.  Pupils pinpoint.  Heroin bag “New arrival” observed in grass near bench.  ETC02, came down to 45 within 2 minutes, respiratory rate increased to 14.  Patient opened eyes shortly after on stimulation.  Sits up on own.  Denies heroin use or opiate use.  Denies any medical problems.  Tells us to “F-off.”  Leaves AMA despite attempts to advise patient of risks of refusing up to and including death.  Seen walking away  with and cussing out woman who FD said had flagged them down when they arrived at park.

The Insulin Refusal

Called for unconscious.  On arrival found 43 year old male slumped over on bench at bus stop, skin cool, clammy.  GCS-3.  P-88, strong.  BP 150/90. RR-16.  Sinus.  BS – 37 by finger stick capillary blood.  IV # 18 in left FA.  Given 15 grams D10 IV drip.  Patient awakes on stimulation, able to state name and recognize surroundings.  States he did not eat lunch as he was busy at work.  Has had trouble of late controlling sugar.  On insulin.  Not on any long-lasting oral meds.  Post D10 BS – 142.  Patient refuses further treatment or transport, but agrees to drink orange juice provided by my partner who purchased it in Dunkin Doughnuts.  Patient also eats sandwich from his bag.  Calls his girlfriend who arrives after ten minutes and promises to watch patient at her home.    Agrees to check sugar regularly and follow with PCP about episode and to call 911 should there be any change in condition.  Signs refusal.  Girlfriend signs as witness.

The Opiate Refusal of the Future

Called for heroin overdose.  On arrival found 28 year old male slumped on park bench, attended by girlfriend, who states patient ODed after injecting 2 bags of New Arrival heroin, which she describes as pure white powder.  GCS-3, respiratory rate -4, cyanotic around lips.  Does not respond to stimulation.  Given 1 mg Narcan IN by FD just prior to our arrival, ventilated with ambu-bag using two person method.  Initial ETCO2-94.  Sinus at 88.  BP 130/70.  No signs of trauma.  Pupils pinpoint.  ETC02, came down to 40 within 3 minutes, respiratory rate increased to 14.  Patient opened eyes shortly after on stimulation.  Sits up on own.  Admits heroin use.  Denies any medical problems.  Thanks responders and girlfriend for helping.  We provide patient with home Narcan kit, information on use, as well as information on where to find substance abuse treatment.  Instruct patient and girlfriend to never do heroin alone, and to always have Narcan handy.  Provide warning about dangers of New Arrival brand, as well as all white heroin, which may contain Fentanyl or other Fentanyl analogues that can be particularly dangerous even to experienced users.  Offer transport to ED repeatedly, patient refuses, but again expresses thanks and promises to follow up with PCP, and will have 911 on speed dial, as well as Narcan handy if he ever uses heroin again.  Understands that Narcan he was given may wear off before heroin does.  Girlfriend promises to stay by his side and call 911 should there be any change in condition. Signs refusal, girlfriend signs as witness.   Seen walking arm and arm with girlfriend across park in direction of local substance abuse/rehab kiosk.

Peace to all.

Bart Simpson Does Heroin

 Bart Simpson is in his parent's Subaru parked to the side of a gas station in Hartford, Ct near the highway ramps.  The car is running, in drive, his foot is on the brake.  He is slumped forward against the wheel.  This has aroused the attention of passerbys who have called 911.  An ambulance arrives within minutes.  The paramedic and EMT get out and try to open the doors which are locked.  The EMT bangs hard against the window, while the paramedic, who has gone to the passenger side, bangs on that window.  He also notices through the tinted windows a second person in the passenger seat, also slumped over.  The banging causes Bart to stir. He opens his eyes, and appears frightened.  He moves his hand to the drive control, but then realizes he is already in drive.  He tries to go forward, but a bus is blocking the intersection and now a police officer is also there yelling and banging against the car. "Stop the car!  Stop the car!"

Bart puts the car in park, and freezes a moment.  The people are shouting and banging against the car. He looks like a trapped animal.  Finally, slowly, he surrenders.  He unlocks the door. The responders open it quickly and yank him out of the car.  The police officer has him put his arms behind his back.  There is shouting.  "Where's your sharp?  Where's your sharp!"

The paramedic opens the passenger door now, which unlocked when the driver's door opened.  The man slumped in the passenger seat, looks up slowly.  His face is hardened and weathered. His pupils are pinpoint, drowsy. The medic recognizes him as an addict who he has seen humping up and down the streets and through the parks of the city. Another officer is there and hails the man by name. "Hey, Charlie, what are you doing in this car? Who's your friend?"

"Bart," he says. "Bart."

"Bart?  Really. What are you giving Bart a tour of the city, huh?  You a tour guide, showing him all the neighborhoods? Is he buying your heroin for you?"

The paramedic sees the needle on the floor of the car and reaches in and picks it up. He takes it back to the ambulance, and disposes of it in the sharps box.  Both passengers are out of the car now and being frisked.

Bart is a short, skinny, pale faced boy of 19 from a suburb.  He is wearing blue Flintstones pajama bottoms, a New York Giants t-shirt and sneakers without socks.  His hair is dirty and matted.  He is crying as the officer shouts at at him.  He finally admits to their doing two bags of heroin.  On the floor of the car are two torn bags.  One says SONY, the other is red and possibly says The Flash, although the stamp is faded.

Charlie is trying to persuade the officer to let him retrieve his backpack from the car because it contains all he owns in the world.  He says he doesn't need to go to the hospital.

Amidst the chaos, Bart ends up in the back of the ambulance, his car gets hooked to a tow truck, and his passenger takes off down the street.  No one is arrested.

In the ambulance, the paramedic tries to console Bart.  His parents are going to be so disappointed in him, Bart says.  He was doing so well.  He was on Suboxone and hadn't used in months.  If only Charlie hadnt called him.

The medic finds out how Bart knows Charlie.  Bart happened to be in a car in Hartford another time also at a gas station after having bought a couple bags of heroin from a contact a classmate had told him about.  Charlie saw Bart sniffing the drug so he came over and suggested that Bart might want to try injecting.  The high is much better he told him.  Soon the two of them were meeting.  Charlie would provide the drug. Bart would pay for them, and Charlie would help Bart inject to make certain he found a vein.  Today Bart paid Charlie $25  for half a bundle. A bundle is typically $35-$40 and contains 10 bags, each about 0.1 gram of heroin (cut with various amounts of other products such as fentanyl, baby formula, rat poison, sugar, and who knows what else).  The medic tries to do the math for Bart.  

"So you guys did two bags?  You paid him $25?  Where are the other three bags?"

Bart looks confused.  

"And let me ask you something," the medic asks. "You both injected right?"

Bart confirms.

"But I only found one syringe," the medic says.

There is silence.

"Tell me you didn't," the medic says.

More silence.

"You two shared the same needle?"

Bart nods glumly.

"Jesus Christ!" the medic says. "You can't do that."

"He only had one needle."

The medic wants to say what were you thinking, but he knows addicts don't think.  The wiring in their brains has gone haywire.  They lack the ability to judge risk.  "Do you have Narcan at home?" the medic asks.

"No."

"You need to have Narcan with you wherever you go.  Your parents need to have it in your house."

"But I was in recovery. I wasn't going to do heroin anymore."

"That doesn't matter. People relapse despite best intentions. You need to get it and your parents need to have it.  And you need to use clean needles.  Your pal Charlie in all likelihood has Hepatitis C and maybe HIV.  He has been around the block.  Addiction is hard, but you need to protect yourself."

Bart returns to sobbing and the medic hands him a Kleenex and feels bad for upsetting him. At the same time he believes the young man needs serious counseling. He has no doubt that Bart's parents love him, and he knows that Bart and his parents face a long road ahead.  

"You can't recover if you're dead," he says. "We need to get you help."

The medic asks Bart, as he asks all of his addicted patients, how he got started on his path.

"I tore my ACL skateboarding three years ago," Bart says.

"Your doctor prescribed you pain meds?"

"I got hooked on them."

"You took more than you should?"

Bart nods. "They made me feel better."

The path he traveled others had tread. Buying pain meds was expensive.  He was introduced to heroin, which he could snort, and which was cheaper. He started coming in to Hartford. Then he met Charlie and his habit became serious. His family put him into rehab and when he got out he was on Suboxone. Suboxone is a opiate that lasts much longer than heroin.  It moderates the cravings, and can be helpful to many people to keep them away from the much deadly opiate. He said he was doing real well.  Just the day before, he had helped his grandfather paint his garage. Then Charlie called, and Bart slipped up. He couldn't resist the thought of getting that heroin high again. Now he was in the ambulance, his parent's car was on the back of a tow truck, and when they found out, they were going to be so disappointed in him.

Bart blubbered.  A nineteen year old boy in blue Flintstones pajama bottoms, paint still on his hands from helping his grandfather.

The medic and his partner help get Bart into a room in the ED, and find him a blanket and pillow, and wish him well.  They remind him about the need to have Narcan available, and to use clean needles, and to never shoot up alone.

The medic tells the ED nurse that Bart has no Narcan at home and that he shared a needle with a known IV drug abuser, who may in fact be Bart himself ten years down the road.  The medic asks that the messages about Narcan and the need for clean needles be reinforced by the ED team.  The young nurse, who is very busy, says  "That's rehab's job. And he should know better."  She later apologizes to them for her comments (overheard by a supervisor), saying she was under stress.

The crew is worried that Bart will simply be observed and then discharged, but he is admitted to the substance abuse wing. While he is being admitted, he tries to escape.  He flees the hospital shirtless wearing just his blue pajama bottoms. But it is very cold out on this November day, and he has nowhere to go. He turns around, and knocks on the ED door.  They take him back in.

Facing Addiction in American

 

On November 17, 2016, the Surgeon General of the United States issued a report, Facing Addiction in America. The 400 plus page report is a fascinating read that draws on the latest research and data to describe the current opioid crisis, the science behind addiction and the best prospects for treatment and prevention.

Landmark report by Surgeon General calls drug crisis a moral test for America

Consider these facts:

Seventy-eight people die of an opiod overdose each day in our country.

Only 20% of people who need opiod use treatment are getting treatment.

The estimated cost to the country of opiod drug abuse is $193 billion a year.

Heroin overdoses tripled between 2010 to 2014. Heroin overdoses are 500% higher than they were in 2014. Overdoses were more than five times higher in 2014 (10,574) than ten years before in 2004 (1,878).

"How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another? Fifty years ago, the landmark Surgeon General's report on the dangers of smoking began a half century of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General's Report on Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can lead healthy and fulfilling lives."

-Vivek H. Murthy, M.D., M.B.A. Vice Admiral, U.S. Public Health Service Surgeon General

The chapter on the science of addiction is fascinating and makes the case for addiction and substance misuse to be largely the result of disease and not character flaw. (More on this in a later post.)

You can download the report here:

Facing Addiction in America

While the report largely ignores the role EMS can play in the fight against the opiod epidemic, I found this statement compelling and can apply to our treatment of these patients we see most everyday.

"This Report calls on a range of stakeholder groups to do their part to change the culture, attitudes, and practices around substance use and to keep the conversation going until this goal is met. Prejudice and discrimination have created many of the challenges that plague the substance use disorder treatment field. These factors can have a profound influence on individuals’ willingness to talk to their health care professional about their substance use concerns; to seek or access treatment services; and to be open with friends, family, and coworkers about their treatment and recovery needs. Changing the culture is an essential piece of lasting reforms, creating a society in which:

* People who need help feel comfortable seeking it;

* There is “no wrong door” for accessing health services;

* Communities are willing to invest in prevention services, knowing that such investment pays off over the long term, with wide-ranging benefits for everyone;

* Health care professionals treat substance use disorders with the same level of compassion and care as they would any other chronic disease, such as diabetes or heart disease;

*People are celebrated for their efforts to get well and for their steps in recovery; and

* Everyone knows that their care and support can make a meaningful difference in someone’s recovery.

In addition to facilitating such a mindset, community leaders can work together to mobilize the capacities of health care organizations, social service organizations, educational systems, community based organizations, government health agencies, religious institutions, law enforcement, local businesses, researchers, and other public, private, and voluntary entities that impact public health. Everyone has a role to play in addressing substance misuse and substance use disorders and in changing the conversation around substance use, to improve the health, safety, and well-being of individuals and communities across our nation."

EMS Fights Opioid Epidemic

 Fighting opiate addiction is every bit as important as fighting the other diseases we encounter -- STEMI, stroke, trauma, sepsis and the like.

There is a tremendous article on the  JEMS website by Dr. Alex Garza and Dr. Sophia Dyer about EMS joining the fight against the opiate epidemic in a broader way than just responding to overdoses and administering Narcan.

EMS Data Can Help Stop the Opioid Epidemic

Read it, and then consider what is happening in your EMS system.

In ours, we are treating increasing numbers of patients addicted to opiates, some who get Narcan, some who don't, some who go to the hospital, some who refuse at the scene.  We see them all, but not all of them get into the system to get help.  Like those scene refusals, many of those who go to the hospital, leave AMA before they get a chance to get counseling.  While not all of them will desire or enter counseling, the health care system should at least be there near to the time of overdose offering help.

The fight against opiate addiction involves many players in the community.  EMS needs to be at that table, sharing what information we have and asking how we can best help -- through data collection to provide real time surveillance, through counseling patients who refuse transport, providing education to family members and friends on overdose scenes about where they can get Narcan for the next occurrence or where they can go to get counseling or into a treatment program, or as some cities are doing, providing Narcan to family members, prealerting EDs to arrival of opiate overdose patients so counselors can be available to provide intervention, and I am certain there are other ways we can help.

I am very excited to be attending such a meeting in Hartford this week, anxious to hear about the efforts community groups are making in the fight, and anxious to hear how we in EMS can best help.

I will report back on the meeting, and other efforts I learn about.

If you haven't already done so, seek out education on the nature of the opiate epidemic and of the disease.  The JEMS article is a great primer.

Election Day

 A 10-year-old girl was shot in the face in Hartford yesterday. She wasn’t walking down the street or riding a school bus, she was in her own home when the bullets raked through the front door. She doesn’t live on a busy street like Park Street or Albany Avenue where criminal activity can be going on at all hours of the day. She was on a quiet residential street with sidewalks and front lawns and single family homes. Clearly she was not the intended target of the bullets, just collateral damage. This isn’t the first time a child has been struck by a bullet in this country much less the first time in Hartford. Kids getting shot is pretty commonplace in urban American. Still I thought for certain it would be a big story of the national news. I envisioned the presidential candidates talking about it in their final speeches before the country. Sadly it is hard to find more than a brief mention of it a day later. An AP wire story, two minutes on the local news the night it happened, and it is already on its way to being forgotten.

A half mile away on the Avenue, the dealers are selling heroin bags with fairies on them.

People can complain all they want. They can rant against Washington. They can call one candidate corrupt and the other a spoiled imbecile. They can choose not to stand during the national anthem. But for damn certain everybody ought to vote Tuesday.

10-year-old Hartford girl shot in the face

Bad Batch?

 Hartford Cops: Rash of Heroin Overdoses Part of Upward Trend

 After a lull of a few weeks, the overdoses started going out again this week.  An hour after I left work Tuesday night, there was a triple OD that is widely being reported in the news, along with two other overdoses not long after.  The papers haven’t reported it, but I know of an additional overdose earlier in the day, who required two mgs of Narcan intranasal to resuscitate as well as a presumption the next day that the medics believed to be heroin related -- a young person with a heroin history found cold and stiff alone at home with no apparent trauma.  That person once toxicology reports are in may well be be added to the list of heroin deaths in the state that is estimated to reach almost 900 this year.

The police are working overtime to determine if this is due to a new bad batch of heroin (perhaps with Fentanyl) or just an anomaly.  My money is on a bad batch.  The police released pictures of the two brands found at the scene.  One skull and cross bones, which has been all around town for almost two months, and the second -- RR Rockafeller, an Australian apparel maker insignia, which is new this week.  The police say they not only want to find and arrest the dealers behind the heroin, they want to alert the substance abusing public to be careful.  I applaud them for this!  Police departments all over the country are recognizing that heroin users are a vulnerable population who need help rather than scorn.

Users will act in two ways due to the publicity.  Some will seek the brands out, hoping it will give them the El Dorado high they have been looking for since they were first seduced by heroin.  They may be cautious about using it, but some will get greedy and no doubt do too much.  These are people whose brains are not functioning properly due to the circuitry damage the disease has inflicted in their heads.  Other users will take caution.  They don’t want to die, they just want to get through the day.  These people need to be warned.  Fortunately the police are working with community groups to get the word out and help keep people safe.  

As far as EMS, we need not only to keep doing our job as we have been, but we need to explore other avenues to help.  These include:

1. Providing overdose information about how to obtain and administer Narcan to people who are on scene at the overdose (Provided your hands are not full resuscitating the patient.
2. Consider initiative that other states have embarked on -- allowing EMS to Pass Out Narcan to family members or friends and neighbors