New Brands

 I called a meeting of the heroin dealers of Hartford at the pavilion in Pope Park. I had no authority to call the meeting since I am neither a heroin dealer nor affiliated with anyone who is.  I just felt like things had hit a critical point where something had to be said.  I admit I was disappointed when no dealers showed.  True about forty men and a smattering of women did come.  They were of various races and tended to dress similarly, hoodies and flat brimmed baseball hats, some wore both hoodies and flat brimmed hats.  But they all assured me they had nothing to do with dealing drugs.  They were opposed to it.  They just came out because they were interested in where I came up with the information there was so much heroin dealing going on in their city.

After first telling them they did not stand so close to me, there was plenty of room to spread out, as far as where I got the information there was a lot of drug dealing in Hartford, I said, What are you serious?  Look around.  Just look at the ground.  See all those ripped bags in the grass.  Pick them up, look at them.  Kong, Amazing, Predator.  Howl.  Those are what the dealers package their heroin in.  (I’ll be talking more about those in a minute.)  And look over there, there's a syringe not 100 feet from the baseball field.  Do you know I have found over fifty syringes in the parks and parking lots of this city.  Look up at Park Street, see those dudes with pale skin and gaunt eyes and backpacks walking up to Frog Hollow and that bearded guy walking with the girl-- they are going there to buy heroin, and then they will come back here to the park.  Like that guy up there on the bench -- the dude who looks like he is about to fall over.  He just snorted some heroin and he is now on the nod.  See that ambulance going by, lights and sirens.  They are going to the laundromat where the fire department is going to have to break down the restroom door again because there is a kid in there turning all purple and stiff from hypoxia caused by the evil drug he just injected into his abscessed arm.  They’ll get there in time to save him, but only because one of the ladies doing laundry, drank too much coffee and had to pee and was upset because the guy who went into the bathroom, stayed in there never came out.  There’s another ambulance right now headed to a house in the suburbs -- in Avon -- where the reaper has already and come and taken a beautiful but troubled young woman away.  She never came in to Hartford herself, but a guy she knew did, and he sold her what he bought here at a jacked up price.  $5 a bag here, $10 in Avon.  Her Dad is doing CPR on her right now even though he knows she's gone.  This can't be allowed to go on.

They nodded a little and said they had heard of such things, but what was I intending to do about it?  And again, they were not dealers themselves, but people were after all, coming in to buy product of their own free will.  The dealers were not exactly giving a hard sell, or so they had heard.  And why was I upset with the drug dealers and not the liquor store owners or the gun shops or the insurance companies who declined people’s medical tests until their cancer was already to advanced to cure or the bankers who gave people loans with confusing terms that they knew they did not understand or could ever pay back?  And what about the pharmaceutical companies who have made billions pushing their drugs without seeing a day in jail or doing one perp walk?

I have nothing to say to any of that I said.  There is a lot wrong with the world.  I’m just trying to deal with this small part of it.

So what’s your message vis a vis the drug dealing?  And are still on that Hello Kitty rant you were on last week.

“Hello Kitty?  You read my blog?”

We like to stay up on what’s happening in Hartford, and we will give you credit on that one.  We found a guy who knew a guy who knew Rafael who was selling Hello Kitty, and once they talked, he said he wanted to apologize.  He had intended to stamp his bags with Dr. Death, but his chihuahua chewed the stamp up too bad to use, so in a panic, he used his daughter’s Hello Kitty stamp, and it hadn’t occurred to him that some user would leave a half full bag in a playground port-o-potty.  He recognized his error, and said he would be more careful, as soon as he sold out the current batch.  It seems Hello Kitty is quite sought after among the fiends, they said.

“Someone read my blog,” I said again.

Yeah, don’t get so full of yourself.  We are busy people, we have to get back to our corners, we mean, our jobs.  What’s on the agenda?

Okay, I said, thanks for keeping me on track.  I get excited and I wander.  But first before I get to the deal, let me just say, "fiends" is not politically correct.  You should be saying "users."  Small point, but an important one.  Now as far as why I called this meeting, here’s the deal.  I have some stamp bags here I had made up.  I know the dealers all have their own brands, and they can still have their brands on the back side or they can use what I have put on there as their new brand.  Let me pass these out.  We can work together on this.  These stamps have important messages that will help keep the dealers customers -- brothers, sisters, sons, daughters, fathers, mothers, friends and fellow souls -- alive.  Is that too much to ask?  We are all just people here.  Let’s help our fellow man.  Here takes these.

They took the bags I offered and some even put in orders for more.  Whether they will take the bags and give them to heroin dealers who their cousins may know or whether they use them themselves to store salt,  pepper, and other spices, I don’t know.  Maybe one bag will find its way to someone in need and be the message that finally gets through.  We’ll see if it helps -- if it makes any difference.  I am running out of ideas.

The meeting broke up with a vague thought that we might have another meeting in the future.  They thanked me for being a paramedic.  One gentleman even said he remembered me from the time he got shot for doing nothing but being in the wrong place.  Another said I had taken care of his mother when she had a heart attack.  A couple had questions about how narcan worked.

I wished I could have talked to the dealers directly, but I left feeling like maybe I had made a difference.

Back at work, I hear another crew send out for a possible heroin OD.  They clear a half hour later with a presumption.  

It's a long road.  No end in sight.

Empty Wallets

 

EMS responders go through more wallets than pickpockets.  Unresponsive person in an alley.  We need to ID them.  Check for a wallet.  Dead person in a hotel.  Got a wallet.  Unresponsive in car.  Check his pockets.  You are looking for the driver’s license, but you can’t help but notice how much cash they are carrying or not.

I will tell you this.  There are a lot of people out there without any green in their wallets.  Particularly opioid users.  Some may have been rolled before we got there, but it seems the same even when we find them in locked bathrooms or cars.  Not a single bill. 

OD in an apartment stairwell.  2 mgs Narcan IN.  Bag for a few minutes.  Comes around.  Immediately goes for his wallet.  It’s not there.  A firefighter holds it.  He has been writing down the demos.  He hands the wallet back to the man, who looks frantically through it.  “Where’s my money?  There was a twenty in there!”

“You were with people when you used?”

“Yeah, my boy,”

“Your boy, here?”

He looks around.  “Where Jamarie at?”  He demands of the onlookers.

“Jamarie knock on my door,” a woman says. “He tell me to call 911.  He save your life”

“Where’s my twenty dollars?”

“Where Jamarie?”

“Shit.”

“Service charge?” I venture.

But what about the fatal OD behind locked doors?  The person who used alone?  They never have any money in their wallets.

I have a theory.

Dude shoots up in fast food restroom.  The bag of A plus he bought on the corner has fentanyl in it, and because fentanyl doesn’t mix naturally with heroin it tends to clump, and he gets a hot spot.  He injects and before he can withdraw the syringe, he starts to seize, his body stiffens, his face turns purple, then blue.  He falls forward striking his face on the toilet.

Enter the Reaper.  Huge man, in black robes, face hidden deep in hoodie.  He looks over the scene, careful not to tamper with any evidence.  He notes the syringe on the ground.  The vomit.  The torn heroin bag.  He finds the wallet in the man’s back pocket.  He's not looking for the ID.  He already has the man's name on his clipboard.  He's looking for green.  A twenty.  He palms the bill.  Dude won’t need green where he’s going, he thinks.  And I have use for it.

EMS finds the body an half hour later, after another customer complains the door is still locked.  A body is blocking the door.  Syringe.  Vomit.  heroin bag.  Not good.  Heart Asystole.  Wallet empty.  We think he spent his last dollar on dope.

Meanwhile across town a young bearded man stands at the intersection by Walmart, looking down at the backpack at his feet.  He holds a sign “Homeless, Need Food.”  His girlfriend sits around the corner, out of sight of the traffic, anxiously watching.

A black sedan drives by slowly.  The tinted window rolls down a few inches, and a boney hand emerges from a black sleeve to hand the man a single bill.

Minutes later the young man and the girl abandon their spot and head toward Park Street.

And awhile after that, sirens.

And so it goes...

No end in sight.

 

EMS Stroke Care

 Stroke Care should follow your local medical direction and treatment guidelines.  Here's how we do it in North Central Connecticut.

EMS Role

When Emergency Medical Services (EMS) recognizes stroke in the field, and notifies the hospital either by radio patch or transmission, the hospital stroke team can be activated prior to the patient’s arrival. With enough notification, the patient can often go directly to CT Scan on the EMS stretcher. This single intervention has led to a marked decrease in door-to-needle time and improvement in patient outcome. The patient can receive an immediate evaluation by hospital neurologists and the decision can be made whether or not the patient meets the criteria for rTPA. The American Heart Association, recognizing the role EMS can play, has established a new goal of door-to-needle time of 60 minutes.  Even if the patient does not meet the narrow criteria for rTPA, the immediate neurological evaluation will lead to swifter interventions such as blood pressure control that will lead to better outcomes.

Stroke Assessment

Prehospital assessment of stroke should center on rapid identification of possible stroke symptoms such as numbness or weakness of face, arm and/or leg, acute vision changes, difficulty in speaking, trouble in understanding simple statements, confusion, trouble in walking or maintaining balance, and sudden severe headache.

The Cincinnati Stroke Scale

The Cincinnati Stroke Scale should be done on every patient suspected of stroke.

Just because a patient may score zero on the Cincinnati Stroke scale does not mean they are not having a stroke.  Posterior strokes, in particular, often present as zero Cincinnatis.

If a patient is zero on the Cincinnati scale, and they have a risk factor for stroke such as history of hypertension, smoking, diabetes, stress, atrial fibrillation, etc., ask these questions:

Did the patient’s symptoms happen suddenly and without an explanation such as trauma or intoxication?

Does the patient present with altered mental status?

Is the patient experiencing a sudden vision problem?

Does the patient have an altered equilibrium or vertigo?

A yes to the first question and a yes to any of the following three questions should heighten your suspicion of stroke as a possible cause of the patient’s condition.

Last Known Well Time

The rtPA clock starts with the onset of the stroke. The sooner rtPA is given the better the patient outcome. As time passes, the potential benefit of rtPA become less effective and the risk of rtPA becomes greater.  Determining when the patient was last seen at their norm is critical. Ask questions. Don’t be afraid to repeat the question to make certain the answers are correct.  Try to transport a witness if possible.

If a patient wakes up with left sided weakness at 6:00 A.M., but his wife states he got up and used the bathroom at 5:00 A.M., then the last known well time is 5:00 A.M.

Blood Glucose

Every suspected stroke patient should receive a blood glucose test. Hypoglycemia can often present with stroke like symptoms that are soon resolved with resolution of the hypoglycemia.

If blood glucose is below 70 mg/dl then administer as little D10 as necessary to restore normal levels.

Do the blood glucose test early in your assessment. A patient who you may suspect has hypoglycemia may be having a stroke, and any delay on scene can affect the patient’s eligibility for rtPA.

Blood Pressure Management

Obtain and record blood pressure. If hypertensive or normotensive, elevate head of stretcher to 30 degrees. If patient hypotensive, lay patient flat (if tolerated) and start IV Normal Saline titrated to blood pressure > 100 mmHg.

History

It is important to get a clear history not only of the event, but the patient’s baseline. Has the patient had previous strokes?  Do they have any residual effects?

 Medications

Is the patient on blood thinners? Do they take Coumadin? Do they take certain medications which will exclude them from being able to receive rtPA? If you can’t get an updated list, put all medication bottles in a bag and bring them to the hospital.

Early Notification

Early notification to the receiving hospital is essential to ensure the immediate availability of an appropriate in-hospital response.

Contact receiving hospital for ACUTE STROKE ALERT and include following information:

* Time of symptom onset/Last Known Well Time

* Description of neurologic deficits (include Cincinnati stroke scale)

* Blood glucose level

When contacting CMED say “I need a radio patch to (Name of Hospital) for a Stroke Alert.” This will help CMED prioritize your patch. Unlike STEMI, it is not necessary to ask for Medical Control.

Scene Time

Try to limit scene time to 15 minutes or less, and transport rapidly. Transport should be equivalent to trauma or acute myocardial infarction calls.  However, in your rush to get the patient to the hospital do not neglect to obtain pertinent information or assist a key witness in traveling to the hospital with you.

IVs

Limit IV attempts due to possibility of patient receiving rtPA. Use 18 or 20 gauge IV if possible.

Neuro Checks

Perform and document vital signs and neuro exam every 15 minutes (on both 911 calls and interfacility transfers involving stroke patients). Neuro exam should include Glasgow Coma Scale (GCS), arm and leg strength, and evaluation of pupils.

Stroke Recognition

The most importation contribution EMS can make to a patient’s recovery is recognition of a possible stroke and notification of the hospital.  Stroke can be very difficult to diagnose and many diseases and conditions such as brain tumors, seizures, migraine, hyponatremia, Bell’s Palsy, metabolic derangements and transient global amnesia can present as stroke mimics.  It is not as important that your correctly recognize each stroke as that you alert the hospital to the possibility that the patient may be having a stroke so they can have a neurologist or team of neurologists available to immediately examine your patient.

Hospital Destination

Unless the patient has a clear hospital preference, the patient should be brought to closest hospital capable of giving rtPA. Currently all destination hospitals in the North Central Connecticut Region report they are ready to treat stroke patients (who meet the proper criteria) with rtPA.  While many patients do not qualify for rTPA, for those that do, any delay limits the benefits and increases the considerable risks.

Direct to CT Scan

Possible stroke patients within the rTPA window (0-3 hours and 0-4.5 hours for some patients) should be brought directly to CT scan on the EMS stretcher if their condition allows and specific hospital policy permits.  The CT scan looks for signs of hemorrhage, or signs of ischemia, which can also rule out rTPA as patients with already visible ischemia are at higher risk for hemorrhagic conversion.  A patient with a clear CT Scan may be a candidate for rTPA.

rTPA

Those patients with clear scans may be eligible to rTPA, which will involve a risk/reward conversation between patient and/or family and the MD.  A meta-analysis of 9 randomized rtPA studies showed rtPA resulted in an absolute 10% improvement (at three months) when given within 3 hours and a 5% absolute improvement when given between 3 and 4.5 hours.  If the patient meets the criteria for rTPA and consent is obtained,  rTPA is given by a bolus, followed by a drip over an hour.

CTA

While the patient is receiving the rTPA drip, they may be taken back to CT scan for a CTA (angiogram) if the patient is suspected to be having a large vessel occlusion (LVO).  If the CTA scan reveals a large vessel occlusion and shows good collateral circulation beyond the occlusion, the patient may be a candidate for endovascular intervention.  If the stroke center does not have an endovascular interventionalist available, the patient may be transferred by EMS directly to an interventionalist suite at an endovascular center with the rTPA still running.  This is known as “Drip and Ship.”

Endovascular

Only a few stroke patients are eligible for endovascular intervention (clot retrieval), a promising intervention which can normally be done up to six hours after time of onset and typically requires the pre administration of rTPA.  A recent study in European Stroke Journal found only 1-14% of stroke patients would have met the criteria for recently published trials that demonstrated benefit to endovascular intervention.  Like rTPA, the success rate for endovascular therapy is far from universal.  In the MR. CLEAN study, 33% of stroke patients who received endovascular therapy in addition to rtPA were functionally independent after 3 months compared to only 19% who received rtPA alone.

Stroke Severity Scales

Several stroke severity scales have been developed in an attempt to help identify patients with large vessel occlusions who would benefit from endovascular intervention.  These scales include the Cincinnati Stroke Triage Assessment Tool (CSTAT), the Los Angeles Motor Scale (LAMS) and the Rapid Arterial Occlusion Evaluation Scale (RACE).  However, according to the American Heart Association “no randomized trial data exist to support a firm recommendation on the acceptable delay in arrival at a stroke center when considering re-routing a patient to a comprehensive stroke center.”   The possible benefits of early endovascular have to be weighed against the “potential harm of delayed initiation of IV alteplase.”  We await further research on this critical question.

Bottom Line

Have a high index of suspicion for stroke.

Notify the hospital with Stroke Alert.

Unless the patient has a clear hospital preference, transport possible stroke patients to the closest stroke hospital capable of rapidly delivering rtPA.

 

Hello Kitty

 

Many years ago, the R.J Reynolds tobacco company got into trouble with its Joe Camel campaign, which featured a cool cartoon camel in human clothing who like to smoke.  The ad campaign was controversial because it seemed to target kids.  The American Medical Association tried to get the company to shut down Joe Camel after a study showed as many six-year-olds knew that Joe Camel was associated with cigarettes as Mickey Mouse was associated with Disney.  Sales statistics backup up a huge increase in underage sales of cigarettes that were also disproportionately camels.  Tobacco company documents were made public that revealed they were indeed targeting kids.  Finally, in 1997, they terminated the campaign and settled to the tune of $10 million dollars to be targeted to teen smoking prevention efforts.

The heroin industry in Hartford seems to be taking a similar tack these days and it is quite disconcerting.  Among the brands to hit the streets in recent weeks are Bugs Bunny, Hello Kitty, Dino babies and Smurfs to go along with the previously issued Casper, the friendly ghost.

Spring is here and the city parks are littered with heroin bags, the small glassine envelopes that contain the powdered heroin and sell for $4 or $5 a bag.  The users sit on the park benches and tear the bags open and snort the fine powder or go down to the pavilion by the pond and squat against the brick pillars, and pour the power into a small cooker or metal spoon, squirt saline water over it, and then heat the mixture to dissolve it and kill the bacteria.  They draw it up in one cc syringes, tie a USB cord around their arm, and hit any vein they can find that is not already sclerosed or ulcered.  The bags, forgotten, are carried on the wind.  Sometimes the users seek the privacy of the Port-o-potty, and a daily check of them reveals the latest brands, cast onto the floor or tossed in the urinal.

I watch a six-year-old run across the playground and enter a Port-o-potty.  I wonder what she will do when she sees the bag with Bugs on it?  Will she pick it up?  On the off chance there is still a few grains of powder in it, will she taste it? or has her mother already warned her?  Stay away from those bags.  Don’t pick up any syringes.  Don’t talk to strangers stay in school.  Study hard.  Don't do drugs.  There’s a better world waiting for us all.

But this is the world we live in, and I think we need to set some ground rules.  I propose we call all the heroin dealers together for a pow-wow in the park.  No cops.  Listen here, we say.  It is not our business to arrest you and put you behind bars – that's the police’s job.  But you need to show some respect for our community here.  If you want to name your product Strike Dead, Killing Time or Biohazard, go right ahead.  You want to call it Nightmare of Elm Street, the Purge or Friday the 13th, be our guest.  Call it Cobra, Scorpion or Black Widow, have at it.  But Hello Kitty is out of bounds.  Same deal with Bugs Bunny, Foghorn Leghorn, Kermit the Frog, and Barney.  Got it.

And while we are it, here are some other rules to think about it if you have any decency.

1. Stop putting fentanyl into brown powder. The folks who don’t want fentanyl are staying away from the white powder because Fentanyl is white and they don’t want to do.  You pretend to sell them fine brown powder by spiking it with fentanyl, shame on you.  You already got them addicted, they have to have their hits, at least let them have the option to avoid sudden death.  Danger seekers can continue to run their risks with white heroin, but please there has to be some boundaries to your deviousness.
2. If you are going to sell Carfentanil, you can only brand it as follows. “Beware…Carfentanil,” Elephant Killer, or Lifetime Supply.
3. Offer Narcan to all your customers, or offer them a safe place where they can shoot up under the watchful eyes of one your boys. If they OD, your boy can give them Narcan, and call 911.  In our state there is no liability for calling 911 for an overdose, unless you are selling drugs at the scene.  Get a lawyer to create a shell company or something so the place where they OD is not directly affiliated with your drug dealing business address.
4. On the back of each envelope you sell, stamp this number. 1-800-563-4086.  It’s the Connecticut Opioid Hotline.  If they call that number they will be connected to the closest walk-in assessment centers where they will be evaluated, and the center will try to find the best form of treatment for them, and help them with insurance issues if needed.  There are 7 assessment centers in the city of Hartford alone.

Our society created many of these addicts through poor policy that lead to widespread availability of painkillers that addicted many of our citizens.  They need to get their fixes somewhere, until they are ready to get clean or there are able to get into treatment.  We recognize drug dealers are filling a demand.  If you are going to be do so, at least be responsible about it.  And of course, none of this will exempt you from police enforcement of the state and federal laws.

And remember, No Hello, Kitty.