Ten Year Old Boy

 Jeanmarie Perrone MD, an emergency physician and medical toxicologist, answers questions from a reporter about the death of a 10-year- old boy in Miami and the dangers of fentanyl exposure.  Hers is a voice of reason in an understandable climate of hysteria.

Miami Boy's Death Shows Powerful Opioid's Chilling Potential

The case is tragic.  A 10-year-old boy walking home from the pool somehow encounters fentanyl and on arrival at home, vomits, collapses and dies, and later tests positive for fentanyl and heroin.

Miami chief: no leads, suspects in young boy's opioid death

Who knows what the final details of the case will be, but the facts of fentanyl exposure remain the same.  Dermal contact is highly unlikely to cause an overdose.  Injection, inhalation or ingestion are the areas of concern.

CDC: Protecting Workers at Risk

The boy did live in a neighborhood known as “ground zero” of the area’s opioid epidemic.  Could he have found heroin/fentanyl on his way home, and either touched the whitish powder (heroin is often cut with sugar or baby formula), and then conveyed it to his nasal membranes or eaten it?

I don’t know how heroin is packaged in Miami, but here is how it comes in Hartford.

Teach your children well.

Fentanyl Exposure: The Toxicologist's Take

 The American College of Medical Toxicology and the American Academy of Clinical Toxicology have issued a joint statement on Preventing Occupational Fentanyl and Fentanyl Analog Exposure to First Responders that states “the risk of clinically significant exposure to emergency responders is extremely low.”

The statement addresses reports of responders suffering overdose from handling or being in proximity to these opioids. Hopefully, this joint statement will help reduce some of the concern and hysteria caused by these stories, and prevent unnecessary delays in treating critical patients without endangering responders.

The statement reads:

“To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids. Incidental dermal absorption is unlikely to cause opioid toxicity.  Reports of emergency responders developing symptoms after contact with these substances have described nonspecific findings such as “dizziness” or “feeling like body shutting down”, “dying” without objective signs of opioid toxicity such as respiratory depression. Law enforcement and EMS must balance safety with mobility and efficiency when entering and securing potential scenes where drugs are used, distributed, or produced. We aim to address the risks of occupational exposures to ultra-potent opioids and the role of various types of personal protective equipment to reduce those risks."

The statement also emphasizes that Naloxone should only be “administered to those with objective signs of hypoventilation from opioid intoxication.”  (A recently issued report by the Drug Enforcement Administration had suggested giving Naloxone on first sign of symptoms.)

The full statement can be read here:

ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders

Here are their key recommendations:

General Precautions and Management of Exposure
● Workers who may encounter fentanyl or fentanyl analogs should be trained to recognize the symptoms and objective signs of opioid intoxication, have naloxone readily available, and be trained to administer naloxone.
● For opioid toxicity to occur the drug must enter the blood and brain from the environment. Toxicity cannot occur from simply being in proximity to the drug.
● Toxicity may occur in canines utilized to detect drug. The risks are not equivalent to those in humans given the distinct contact that dogs, and not humans, have with the local environment.

Dermal precautions
● For routine handling of these drugs, nitrile gloves provide sufficient protection.
● In situations where an enclosed space is heavily contaminated with a potential highly potent opioid, water resistant coveralls should be worn.
● Incidental dermal exposures should immediately be washed with copious amounts of water. Alcohol based hand sanitizers should not be used for decontamination as they do not wash opioids off the skin and may increase dermal drug absorption.

Respiratory precautions
● In the unusual circumstance of significant airborne suspension of powdered opioids, a properly fitted N95 respirator or P100 mask is likely to provide reasonable respiratory protection.

Mucous Membrane/Splash Exposure
● OSHA-approved protection for eyes and face should be used during tasks where there exists possibility of splash to the face.

Naloxone Administration and Airway Management
● Naloxone should be administered to those with objective signs of hypoventilation from opioid intoxication.
● If hypoventilation persists following initial naloxone dose and personnel with advanced airway training are not available, repeat naloxone until reversal is seen or 10 mg is administered.
● Personnel with advanced airway training should provide airway support for patients who are in extremis or those who do not improve with naloxone.

Long-term Sequelae of Exposure
● In the absence of prolonged hypoxia, no persistent effects are expected following fentanyl or fentanyl analog exposures. Those with small subclinical exposures and those who awaken normally following naloxone administration will not experience long-term effects.

Stay safe and use appropriate PPE.

Mother and Son

 

The woman with the cellphone stands outside the car. She explains that the male in the car has been smoking crack, taking benzos and doing heroin for several days. I ask if he is breathing. She says yes, but he is asleep right now. When she picked him at his friend’s house in their suburban town an hour earlier, he was out cold. His friends were going to give him Narcan, but the girl with them said don’t waste it. The girl then punched him hard twice in the chest and put ice in his pants.  I ask what is her relationship to the person in the car. He is my son, she says.

I approach the car. A heavily tattooed man wearing basketball shorts and an NBA jersey is fully reclined in the passenger seat. His mouth is open and his eyes are shut. I can’t tell if he is breathing. A police officer is standing next to me now. He opens the front door, I open the back door. A sternal rub and the man springs forward. “What? What the fuck!” he says. “What’s going on?” He is in his mid-twenties, a powerfully built thick necked young man with short hair and missing teeth. “What the fuck? Mom? Where did you take me? Hartford? The cops? Really? Mom, really?”

“You need help,” she says. “You need rehab, and your foot is infected.”

“My foot is infected. Yeah, my foot is infected. I’m a drug addict! Mom. Of course, it’s infected!”

The officer says, “I’ve dealt with you before. What’s your name?”

“Not me.”

“No, I’m sure I have.”

“It was probably my brother. We look alike. People mistake us.”

“Maybe.”

The mother says, “You need to let them take you to the hospital.”

“No, I’m not going to the hospital. You’re taking me back to my boyz. I can’t believe you did this?”

“I’m not taking you back. You either go to the hospital or you can walk home.”

“Walk home? It’s twenty miles! I don’t have socks. You’re going to leave me here on my own in Hartford without socks and shoes!”

“You have shoes right there.” I point to the sneakers by his feet.

“These aren’t my shoes! Jesus, Mom, you could have at least grabbed my socks!”

“Maybe its cause your feet are swollen.”

“I told you I’m a drug addict.”

“He injects in his feet,” his mother says. “He just got treated for an infection, but it’s worse.”

“Please, dude,” he says to the cop. “Make her take me back to my boys. That’s cold what she did.”

“It’s between you and your mom.”

“I don’t want you in my car,” she says. “I don’t want to see you anymore. I am done with you and your brother both.”

“Fine, but give me a ride back to my boys. You brought me down here now take me back!”

“Your mom wants you out of the car,” the officer says, “It’s her car. You have to get out.”

“But I have no socks. I have no socks! That’s not fair.”

“It’s not fair,” the officer says, “but you’re a man, you have to deal with it.”

“Mom, just take me back. Take me back to my boyz.”

“I can’t take this any longer,” the mother says.

“I have no fucking socks!”

This goes on for about fifteen minutes. It is like a symphony with repeating refrains and instrumentation. “I have no socks.” “I’m done with you.” “Be a man.” “I’m a drug addict!” “I can’t take this any longer!”

In between there are some actions. He knows where he is, the date and the president. He denies suicidal thoughts. He tries to light the butt of a cigarette found on the floor boards. His mom says he is going to kill himself. He misses all his rehab appointments. He apologizes for that, sincerely, he says, but says he is still not getting out of the car. She is worried about the fentanyl and the elephant drug. And she can’t spend her nights looking for him anymore. She is sixty years old, she says and she is tired.  Still not getting out of the car.  I tell his mom how to get Narcan by going to the pharmacy and getting the pharmacist to write her a prescription on the spot. Insurance will pay for it except for a small copay. She should always have it on her. But she doesn’t allow her sons in her house anymore, she says. But you’re still involved with them, I say. Yes, she nods, she is.

He says now he hasn’t eaten for days, we point to the hospital and say he can get a hot meal there, and he can get his foot looked at.

“I’m not going to the fucking hospital. I got to get back to my boyz!”

“All right, all right,” the mother finally says. “I’ll take you back to your boys if you just shut up. After that I’m done with you!”

The officer asks her if she is sure, if she feels safe with him.

“He is my son,” she says.

I tell her again how to get Narcan and to keep it in her purse.

She nods and says, she’ll do it.

She gets in the car. “Put your seat belt on,” she says to her son.

He shakes his head, but he puts the seatbelt on.

They drive off.