Sunday, October 28, 2018

Chains

 

We’re sent to the courthouse where a marshal takes us back to a holding cell. A thin, bearded man with cuffs around his wrists and his legs chained is bent over in the bare cell, grimacing.

“Guess he got nervous about seeing the judge,” the marshal says to us, “Developed himself some back pain.”

“I’ve had back pain all day,” the man says. “And I’m not ducking anything. I’m in here for panhandling for Christ sakes! I can’t fucking sit up.”

“You didn’t tell that to the officer who brought you here?”

“He knew I had pain. I was sitting on the side of the road, holding my sign. I couldn’t even stand up. He had to help me into the god damned squad car. He brought me right here. I’ve got a warrant for failure to appear for another panhandling charge. Big bad criminal, that’s me.”

There is a term called “jailitis” that implies that prisoners are faking sickness to get out of jail, knowing they have to be brought to the hospital, and even though they know they will be returned to their cell eventually, the trip breaks up the monotony of their time. It is so common that jailors tend to lose the belief that anyone in their cells could ever really be sincere about their conditions. They call us per policy only to avoid liability should anyone truly be sick and not get care.

“I’m in terrible pain right now,” the man says to the marshal. “I’m always in pain, but not this bad. Plus in another hour, I’m going to puking and shitting myself.”

We transport the man with one hand cuffed to the stretcher railing and a police officer following us in a squad car. The prisoner tells me his tale. He is from a town in eastern Connecticut and he comes to Hartford to buy fentanyl. He says he hurt his back in a construction accident ten years ago. He went to a pain doctor who overtime increased his pain prescription to three 80 milligram oxycodones a day.

“Then one day I go in and his receptionist tells me he got arrested. No other doctor would take me. I’m on three 80 milligram oxycodones, for Christ’s sake!  What choice did I have then? Just stop taking it?” He shakes his head. “Let me tell you. You don’t ever want to go through withdrawal. I’ll do anything to avoid it.”

He is only forty-two, but he looks like he is in his late fifties. His face is hard, deeply lined. His tortured blue eyes look like he knows what it is like to be chained in a dungeon. He reminds me of the character in the old Far Side cartoons who is, in fact, always chained to a wall. The only difference is this man is real and nothing about his condition is funny. “Withdrawal -- it’s fucking hell,” he says.

Friday, October 26, 2018

Unforgiven

 

He is walking down a side street off Park when he freezes in place. He sees the slow moving black Toyota blink its lights, then he sees the station wagon. Before he can take a step to flee, he sees the barrel come out of the back window. He feels the impact against his shin and another in the hip. He dives behind the bus stop shelter as more bullets splat against the wall of the boarded up store behind him.   He scrambles up and runs into the street. He takes the orange he has in his pocket and heaves it at the car. Then he holds up a double barreled middle finger. “Fuck you! “ He shouts. “Your product sucks!”

“Five times I’ve been ambushed this week,” he explains to me that afternoon. “He hit me eight times. Hurts like a mother. Look at me, I’m covered in paint. He uses a different car for his shooters every time.  He flicks his lights to give them the signal, the bastard.”

Mickey is a homeless addict who is a fixture on Park Street. He is short and wirey and missing most of his teeth. Every six months he disappears for awhile, going to stay with his aunt in rural town in the northeastern part of the state. Invariably, I see him back on Park Street. He doesn’t want to be an addict for the rest of his life, but staying with his aunt in the country makes him stir crazy. He has nowhere to go in the town. He can’t drive, he has no friends, there are only so many chores you do around the house and only so much TV to watch. He gets the urge to call old friends, and then he fucks up and he is back on Park Street. While Park Street has heroin and he knows heroin will kill him one day (He’s already had a heart valve replaced due to endocarditis); on Park Street, Mickey is somebody. He has acquaintances. People know his name, even if one of them is trying to hit him with paintballs.

The paintball attacks started five days ago when, not able to find his normal dealer, he bought an unmarked bag off another dealer he knew.

“Four dollars” the guy told him. “It’s great. Four dollars.”

“It’s not all cut with that crazy stuff.”

“Four dollars. You’ll love it.”

He forked over his bills.

It gave him what he called a bad weed high. He felt all dark and paranoid, almost catatonic, all the while his heart was racing. He felt like crap for the rest of the day. When he tried to get his $4 back, the dealer told him to fuck off, so he invested the better part of two days telling everyone on the street, the dude’s product sucked and now no one will buy it. The dude even changed his brand, and still no takers. Mickey has a big mouth. He laughs when he tells the story. “So he’s pissed at me.”

“You have to be careful you don’t get hit in the face.”

“All the shots so far have been below the waist. That’s the code. I’m worried he’s going to get me in the nuts. I got newspaper there for padding.”

I had to admit I laughed about the comic manner of Mickey’s storytelling and the thought of a pissed off drug dealer chasing a wise-guy half-pint all over Park Street and surrounding side streets with a paintball gun. Mickey’s a tough guy, and he uses humor as a shield against the cold realities of his life. Despite his bravado, I have also seen him cry talking about all the times he’s been beaten up for fun, and I’ve seen him sick and looking like death in the waiting room of a clinic he was checking himself into in another attempt to get clean and get off the streets.

I hope Mickey is forgiven by his tormentor.  I hope the feud ends quickly.  And as painful as paintballs can be, I am grateful they are not bullets.

 

Wednesday, October 24, 2018

In Praise of Tim Phalen

 

If you ever get a chance to take a 12-lead class from Tim Phalen, Don't miss it. Tim has been teaching 12-lead classes across the country for over twenty years. I first took a class from him about that long ago. He is a great presenter with the gift of making complex concepts seem easy.

When I first took his class, he told a story about Elvis the janitor, who he and his buddies taught how to read 12 lead ECGs. Elvis would be mopping the ED floor and then peer over the shoulder of a medical resident intently studying a new ECG. “Inferior MI,” Elvis would say, and then continuing mopping. A few hours later, he would glance at another ECG the resident had just obtained. “Anterior.” And back to the mopping, He became a legend in the ED for his savant-ability to read ECGs. How did he did he do it?

Simple. Tim and his buddies taught him Big and Tall is Bad. Lower corner is inferior, The right side of the page is Anterior.

Wallah!

Phalen, of course, teaches to a level of detail far greater than Big and Tall is Bad, but if through simple concepts he can teach a medically untrained janitor to recognize a STEMI, think of how effectively he can teach a paramedic to recognize a patient with a left bundle branch block who is also having a STEMI.

I’ve bought several of Tim’s ECG books over the years, mainly to replace ones I’d lend out that got relent and never returned. His books are well done, easy to learn from, and well worth the price.

I was excited recently to learn that Tim would be presenting a 12-lead class at our service.

In EMS, we sit through so many presentations that are dull and boring. Death by PowerPoint. I’ve been guilty of it myself. Watching Phelan is watching a master. His ability to keep things simple, and to circle back with repetition so the key points sink in is masterful.

Since the audience was experienced medics, he focused on more advanced concepts rather than an introduction to 12-leads in the three hour class he gave us. The STEMI equivalents and the imposters. I had heard of Wellen’s sign, DeWinter’s T waves, Brugada Syndrome and Scarbossa before, but I understand them much better now. He also covered Left Main Equivalent/Triple Vessel Disease, post ROSC ECGs, as well as Left Ventricular Hypertrophy, Bundle Branch Blocks, Early Repolarization and Pericarditis with helpful simple tips to recognize them.

My fellow medics were all very excited afterwards, and anxious to go out and do 12-leads. The best EMS classes get you fired up about your job and Tim Phalen certainly accomplished that.

Kudos also to Mike Hooper, a name well know in this region, who has been the sales rep for Physio products since I can remember. Super nice guy. He taught us a class recently on how to use our new Life Pack 15s and accompanied Tim on his recent teaching tour of the area.

The latest edition of Tim's book with updated material  will be coming out in November and will be available on Amazon.  You can pre-order it here:

The 12-Lead ECG in Acute Coronary Syndromes 4th Edition

Friday, October 19, 2018

Obituary

 

I see Maria outside the Spanish market, squatting against the building. She is a tiny woman in her fifties who was introduced to heroin thirty years ago when she was living in New York. The father of her son used it occasionally and when he used, she was obligated to sniff some as well. It didn’t take her long to get addicted. She has grandkids, but she never sees them. Her father is still alive, but even though she misses him terribly, she doesn’t want him to see what she has become. She says she would like to quit, but she has no help. She stays here and there, and is dependent on people coming out of the market and giving her their loose change. She doesn’t beg or ask or bother people, she is just squatting there. People who know her and know what she needs hand her some change. When she gets four dollars, she walks a block and goes behind a cafe and buys from the guys in the back lot. “No Fentanyl,” she tells them. She just wants heroin, enough to keep her from being sick.

I’ve taken her to the hospital a couple times. Once when she fell and cracked a bone in her leg. A week later, she was back on the street, hobbling on a cast. Another time, over a year ago, we found her in the alley with the needle still in her jugular vein. She was breathing and we could rouse her with stimulation, but she was zoned out. She cried on the way to the hospital. She had a small bag with her. In it were clean needles and a cooker she got from the needle exchange van, along with a portable sharps container. The hospital confiscated it, and she had to go back to the needle exchange van and plead for more needles which they gave her. They have a "one used for one clean" needle policy, but can be persuaded to give more. They know people will pick up needles off the ground and use them if they have to. When I take people to the hospital now, I try to tell the staff that these clean needles they have are legally theirs and shouldn’t be summarily tossed. I had to get a doctor once to order the staff not to throw them out.

Last year I was going into the market and asked Maria if she was hungry. I had her come into the market with me.  She pointed to a sorullo in the glass display case, fried cornmeal with cheese in the middle. “Can I have something to drink, too?” She asked. She pointed to a can of Kola, which I had the woman behind the counter get as well.

The next time I saw her outside the market, I said, “You want me to buy you a sandwich or do you want two dollars?”

“Two dollars,” she said, quickly. I gave her the money and then went inside and ordered her a sorullo and a Kola, which I gave her in a small paper bag when I came back out.

“We have to put some meat on your bones,” I said.

My coworkers and I discuss how to handle the homeless. Most say they offer to buy food, but never give money. There is a guy who hangs outside Burger King named Johnny. He is in his forties, a thin hard-faced man with hair to his shoulders, who is always sitting there head down reading a paperback thriller. He also relies on people to hand him change. My old partner Jerry often invites him in to buy him a meal. When I see him, I chat with him for awhile and then give him a couple dollars and a bottle of water.  Let him decide what he wants to do with the money. (His story is he got in a bad car accident in his twenties.  His doctor gave him Percocets in increasing doses for two years and then one day just cut him off cold, saying he shouldn't be in pain anymore).

Last Thanksgiving, I brought in turkey and gave out portions to several of the regular homeless addicts I know. They were all very grateful, but I heard later from two of them that it made their stomachs upset because they were not used to eating fatty meat. I have read that when people are addicted to heroin, eating ranks low on the totem pole of desire. They eat only to have enough strength to be able to raise the money and then go get the dope they need to keep from feeling sick. If they did a study on the homeless and addicted to heroin diet, no doubt its adherents would lower their percentage of body fat. The exercise of walking all day and not eating does the trick.

My partner and I give out oranges and apples and the homeless will sometimes eat those fruits in front of us like the zombies of the walking dead eat people. Still I think if I asked do you want orange or a dollar, they would still take the dollar. The orange might satisfy their hunger, but the dollar will help them buy their next bag of heroin, and the heroin will help them feel better.

It is pouring rain this morning. A young woman named Cloey stands in the rain holding a “Homeless and Hungry” sign. I have only seen her a couple weeks so I don’t know too much about her. She has a nice smile and a girlish manner to her words. She could be a friend of my daughter.

It is still early in the morning and I haven’t stopped at the grocery yet to get a bag of oranges. I don’t even have any dollar bills in my pocket. I do have some water in the cooler, and a pocketful of change. We stop and I get out and give her a water and some change, maybe a $1.73 or some odd number like that. I ask her how she is doing, and she thanks me, but says “I am really sick this morning.” I feel bad for her. Some day when I get a chance to talk with her further I will ask her what happened? What were the turns in her life that brought here out to these streets, begging for change in the rain?*

I see her briefly that afternoon. The rain has stopped and the sun shines through the clouds and starts to bake the water off the asphalt and grass. It’s not yet humid but it soon will be. She waves as she walks by, and then she stops briefly and says. “Thank you for this morning. I’m feeling much better now. I was really not doing well. Thank you.”

“You want a water?”

I hand her a water from the cooler I keep at my feet in the front of the ambulance. She takes it and gives me a young girl’s smile, before she walks back up toward Park Street.

I have heard people say if you want to help the homeless, give money to social organizations who help the homeless instead of putting the money directly in a homeless person’s hand. It goes along with the expression, “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” This implies that the money you give to the heroin addict only buys them a few hours of not being sick and they are back to square one when the money given to the organization may eventually help lift them out of their circumstances. I don’t dispute that. I do give small donations to the Greater Hartford Harm Reduction Coalition to help them with their efforts to keep people alive until they are ready to enter recovery. But I also give money directly to the homeless. It is not a lot of money. Just spare change really. I don't consider myself a generous man.  I hang up on telephone fundraisers and don't answer the door when charities come collecting with tin cups in their hands.  I walk right by them when they stand in front of the supermarket.  I am not a Sunday church goer so I don’t put my weekly tithe in the collection plate. In a way the city I have worked in for much of my life is my church. When I give money to a homeless person, it makes me feel spiritual -- as a human being, I feel less alone in the world. I hope it makes them feel that same way. We should all feel connected.

* I get a chance to talk with her a week later.  She was born to a 14 year old mother, who gave her up at a young age because she was a heroin addict.  She is still alive, a homeless addict herself in a Western city.  Cloey tells me she tried heroin as a teenager because she wanted to know what it was about the drug that could cause her mother to care more about heroin than her own child.  "As soon as I tried it," Cloey said.  "I understood."

Obituary

 

I had three people tell me to read this obituary a woman wrote about her sister who died at thirty-two after a long struggle with addiction.

Madelyn Linsenmeir, 1988-2018

Powerful.  

While I am most moved by the first part that describes Madelyn and shows the clear love of her family for her, I am excerpting the end below because it contains a message for us as health care professionals.

If you yourself are struggling from addiction, know that every breath is a fresh start. Know that hundreds of thousands of families who have lost someone to this disease are praying and rooting for you. Know that we believe with all our hearts that you can and will make it. It is never too late.

If you are reading this with judgment, educate yourself about this disease, because that is what it is. It is not a choice or a weakness. And chances are very good that someone you know is struggling with it, and that person needs and deserves your empathy and support.

If you work in one of the many institutions through which addicts often pass — rehabs, hospitals, jails, courts — and treat them with the compassion and respect they deserve, thank you. If instead you see a junkie or thief or liar in front of you rather than a human being in need of help, consider a new profession.

We take comfort in knowing that Maddie is surrounded by light, free from the struggle that haunted her. We would have given anything for her to experience that freedom in this lifetime. Our grief over losing her is infinite. And now so is she.

 

Tuesday, October 09, 2018

Supraglottic Versus ET

 

“EMS personnel and physicians involved with protocol development for EMS systems in the United States, United Kingdom, and similar settings with limited exposure to advanced airway management should reconsider the routine use of endotracheal intubation as the first-line strategy for airway management in out-of-hospital cardiac arrest.”

This is the conclusion of an editorial in the August 28, 2018 edition of the Journal of the American Medical Association.

The editorial, “Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest,” is in response to two major new prehospital randomized, controlled airway studies published in the same edition of the journal.

In the first study, the Pragmatic Airway Resuscitation Trial (PART), researchers found initial insertion of a laryngeal tube (King-LT) in victims of cardiac arrest “was associated with a significantly greater 72-hour survival compared with a strategy of initial endotracheal intubation.” The authors found that a King LT Airway outperformed the endotracheal intubation in every category in which they compared, including a 2.7% better increase in survival to hospital discharge, which would translate into 10,000 additional lives saved nationwide.

The second study, AIRWAYS-2, did not find a statistical difference between using a supraglottic airway (igel) and endotracheal intubation. These were both high quality studies conducted at many sites in the United States (PART) and Great Britain (AIRWAYS-2).

The Pragmatic Airway Resuscitation Study (PART) enrolled over 3000 patients and was conducted by 27 different EMS services in 5 metropolitan areas over the course of two years.

You can read the studies and editorial here.

Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome The AIRWAYS-2 Randomized Clinical Trial

JEMS has an analysis of the study here:

ETI vs. SGA: The Verdict Is In

There have been many other analyses of the studies on medical sites.

The Great Prehospital Airway Debate

AIRWAYS-2

Why are we still intubating, when there is no evidence of benefit and we refuse to practice this “skill”?

EM Nerd-The Case of the Needless Imperative

What does this mean?

Here in Connecticut, we no longer consider the endotracheal tube as the gold standard for airway management. Supraglottic airways can be either the primary or backup airway based on the circumstances of each call.

Additionally, ET is limited to three attempts.

Before we went to statewide protocols, our regional guidelines limited ET attempts to two by the first medic, and one additional attempt if another medic is present and wants to try.

That works for me.

I am not ready to give up on ET intubation. It remains my preferred method, but I do not hesitate to drop a combitube from the get go if I am presented with a patient who I suspect based on their anatomy or where they lay, will be a difficult tube. I once immediately dropped on combitube in an obese patient in a hospital bed that was shoved into the corner of a room in a horder’s house. Fifteen seconds later, I had an airway. If I had gone for an ET, I wouldn’t have even had my ET roll unzipped, and the tube and stylet and syringe unwrapped from their sterile packaging, much less having to move the bed and patient and all the crap in the house that would interfere with that.

If a medical director told me that based on his reading of the literature and his worry that the risk of ET intubation in the hands of unskilled medics was too great and that we should remove ET intubation altogether, I would understand and would have a hard time protesting too loud.

Remember: The important airway goals are safely securing the airway in a timely fashion, avoiding interruptions in chest compressions, and limiting attempts. In cardiac arrest, the only two interventions proven to improve mortality are quality chest compressions and timely defibrillation.