Connecticut Overdose Deaths Plateau

 Overdose deaths are declining in some states, and they appear to be plateauing in Connecticut.

Overdose Deaths Fall in 14 States

In data released by the CDC, covering the time period July 2016-June 2017, 14 states showed a decline in overdose deaths, while nationwide deaths rose 14 percent. The data showed an 15.9% increase in Connecticut, but even more recent data released from the Connecticut Medical Examiner’s office tells a more promising story. 

Number of Connecticut overdose deaths surpassed 1,000 in 2017

While deaths increased by 11.7 percent in Connecticut between 2016 and 2017, the last six months of 2017 showed a 8.7% decrease from the first six months of the year.

This is still a horrendously high level of overdose death, and it may only represent a temporary lull before escalating, but it does reflect what I have been sensing lately.   Over the last several months, 911 calls for overdoses are still abundant, but they don’t seem to be getting worse.

As to why the death rate may have plateaued, it is an open guess. The increased availability of community Naloxone may be a contributor. Also, perhaps, the knowledge that much of the heroin in Connecticut is either heroin (and cut) laced with Fentanyl  or just plain cut and Fentanyl, has caused users to use more caution, doing test shots and making certain they are using with someone else, and have Naloxone available.   Without better data, it is hard to say for sure.  At any rate, the decline in the latter half of 2017 is at least promising.

Graphs by P. Canning based on Medical Examiner's data and published news stories.

(Note:  These graphs were updated on March 1 to refelect Medical Examiner's official number released on this day.  They were slightly different from previously published news reports.)

Calendar Years 2012 to 2017 Accidental Drug Intoxication

Connecticut Drug Deaths Top 1,000 Last Year; Fentanyl Jumps As Heroin Declines

Common Cardiac Arrest Mistakes: Sodium Bicarbonate

This is the second of three posts about common cardiac arrest drug mistakes some EMS personnel make on a routine basis.

You have been working a cardiac arrest for a 54-year-old male with no prior medical history who collapsed after grabbing his chest.  You shocked him twice for fine vfib, but now he is in a PEA. It’s been 20 minutes since you started ALS interventions and another medic suggests you try sodium bicarb.  What do you do?

Remember it 2019, not 1979, 1989, 1999 or 2009.

Unless the patient has preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressenat overdose, (which this patient clearly does not) sodium bicarb is not recommended by the AHA.  In 2010 sodium bicarb was made a Level 3 Recommendation.  Level 3 means it is not helpful and may be harmful. In 2015 that recommendation was reviewed and maintained.

While you should always follow your protocols and your local medical direction, in Connecticut, sodium bicarb in cardiac arrest is reserved for “suspected pre-existing metabolic acidosis, suspected or known hyperkalemia (dialysis patient), known tricyclic antidepressant overdose, or suspected excited/agitated delirium.”

So if your patient is a dialysis patient or laying next to an empty pill bottle of amitriptyline, you can go ahead and give sodium bicarb.  Make certain the patient is getting excellent CPR and is well ventilated.

Just don’t give bicarb to “routine cardiac arrest," only use bicarb for special situations.

Here’s an excellent article on this issue:

Sodium Bicarbonate Does Not Work in Cardiac Arrest

As the author writes: “The literature behind using sodium bicarbonate in undifferentiated cardiac arrest clearly shows it does not work and may even be harmful. The AHA recommends against its routine use. So stop using it.”

https://www.sciencedirect.com/science/article/pii/S0300957217303337

Here's a recent journal article, which examined the "association of SB administration and survival and favorable neurological outcome to hospital discharge," and found in "OHCA patients, prehospital SB administration was associated with worse survival rate and neurological outcomes to hospital discharge."

Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest

Next: Naloxone in cardiac arrest. 

Sepsis

 EMS has focused on trauma, stroke and STEMI in recent years with resulting improvements in outcomes.  Many health care systems are now turning attention to sepsis care and the considerable role EMS can play in early recognition and treatment.

Here in Connecticut we have Sepsis Alerts, which while rarely generating the full response of Trauma, Stroke and STEMI Alerts are important to help hospitals be able to quickly recognize sick people on entry and devote them more immediate attention than they might otherwise receive.

EMS can start the treatment soonest with aggressive fluid resuscitation for those who meet the indications.

Great material on sepsis is available at this web site:

Sepsis Alliance

Check out this excellent video:

Learn to recognize sepsis:

IDENTIFICATION OF POSSIBLE SEPTIC SHOCK

Suspected infection – YES

Evidence of sepsis criteria – YES (2 or more):

o Temperature < 96.8 °F or > 100.4 °F.

o Heart rate > 90 bpm.

o Respiratory rate > 20 bpm.

o Systolic blood pressure < 90 mmHg OR Mean Arterial Pressure (MAP) <65 mmHg.

o New onset altered mental status OR increasing mental status change with previously altered mental status.

o Serum lactate level >4 mmol/L if available and trained.

-From Connecticut EMS Treatment Guidelines

 

Goals and Globetrotters

 Saturday night saw one of the pinnacle achievements of my life.  Twelve months before, while attending a Harlem Globetrotters game with my daughter, I announced that I was going to learn how to expertly spin a basketball on my finger just like the Globetrotters do.   Ever since then, I have carried a basketball in the ambulance.  In between calls while at posting locations, I have taken the ball out and practiced.  At home I have a basketball in every room of the house.  I even found a heroin addict in Hartford who for $5 a pop would give me spinning lessons. He was an ex-basketball player, who I am pleased to say now has a handyman business and is no longer on the street. (At least that was his plan when a few months ago, he told me I wouldn’t be seeing him around anymore, and true to his word, he disappeared no longer to be seen at his regular haunts.  I can only hope he is doing well).  I practiced so much I developed tendinitis in my elbow and had to suspend all spinning for a month. The elbow is much better and I can spin again without pain.

When I received notice that the Globetrotters were coming back to Hartford for their annual visit, I purchased Magic Passes for my daughter and I as well as third row seats at mid-court.  As a returning attendee, I took advantage of the 50% deal when the tickets were offered in a special pre-sale.  The Magic Passes entitled us to attend a pre-admission event where we could meet the players on the court, shoot baskets and spin basketballs.

Thanks to my daughter, my tryout was recorded for posterity.  Behold!

We had a great time, the Globetrotters stormed back from a 9 point deficit in the 4th quarter and beat the hated Washington Generals in a thrilling victory.

My daughter met "Swish,"a female Globetrotter.

While I was not offered a contract, I did have the opportunity to buy an official game ball for $60 and a Washington Generals t-shirt for $25.  I spoke briefly with the Generals and told them should “Cage” their 7-foot starting center and noted villain leave for other opportunities, I would be available to don the black mask.

I write all of this because my ability to devote a year to spinning a basketball is one of the great side benefits of being in EMS.  Over the years, EMS has allowed me to pursue a variety or hobbies and interests while at work getting paid simply to be available to respond to emergency calls.  In the 30 years I have been involved, I have read the works of Shakespeare, written five books and countless blog posts, learned to play poker (and when it was legal to play on-line, made a fair amount of extra cash), trained for triathlons and Tough Mudders (when I was assigned to a contract town, I was able to ride my bike on a 0.7 mile loop around the industrial complex where the ambulance base was located -- my longest at-work ride was 26 miles), learned to speak Spanish, failed in an attempt to learn Vietnamese, wrote a food blog on take-out food in Hartford, trained to perform a 100 push-ups in a row (okay, so I only got to 79, and started cheating at 57), amassed one of the nation’s premier heroin bag collections, and now have learned to spin a basketball.

So what’s next?  I think I will work on my balance with a goal of standing on one foot for ten minutes.  My longest time on 10 tries today was 1 minutes and 49 seconds on my left foot and 1 minute and 36 seconds on my right.  I am six foot-nine and sixty years old, so not only is my balance not great, with each advancing year it becomes less so.  I need to improve upon it if I am going to be able to keep at this job I love.

Wish me luck.

Common Cardiac Arrest Mistakes: Naloxone

This is the third in a series of posts on common drug mistakes some EMS responders make during cardiac arrests.

You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

You set your monitor by the man’s head and connect the fire department’s pads to your monitor, while your paramedic student quickly places an IO in the man’s tibia. As you approach the two minute mark, you charge the monitor, and then order stop CPR. The patient is in asystole. “Continue CPR,” you say, as you harmlessly dump the charge by hitting the joule button.

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

What drug do you give?

***

Epinephrine.

According to the 2010 AHA Guidelines

There is no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.

Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms

Naloxone has no role in the management of cardiac arrest.

Opioids bind to brain receptors that suppress respiration. The patient, if not treated in time, becomes hypoxic and may soon go into cardiac arrest. Giving the patient in asystolic arrest Naloxone will do nothing to restart the patient’s heart. The patient is in the same condition as someone who has suffered an airway obstruction. Hypoxia is the killer. The patient without a heart beat will not be able to breathe on their own without restoration of the heart beat. You are already taking care of the breathing part with your bag-valve mask.  The priority is getting the heart restarted. That is what epinephrine does.   This patient needs good CPR. Ventilation with a bag-valve mask and epinephrine to get his heart started.

***

Case # 2

You are a basic EMT. You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

You feel for a pulse, but find nothing. “Continue CPR,” you say.

What do you do next?

***

Naloxone.

Why? Because even though you can’t feel a pulse, the patient may have a hard one to palpate. He may, in fact, just be in respiratory arrest. You can give Naloxone while you provide CPR. If the patient is in a narrow complex rhythm, they may resume breathing on their own. If you are a medic in this situation and you find a pulseless man with a narrow complex rhythm, you should give Naloxone, while continuing to perform CPR.

The AHA Guidelines for BLS state:

Patients with no definite pulse may be in cardiac arrest or may have an undetected weak or slow pulse. These patients should be managed as cardiac arrest patients.

Standard resuscitative measures should take priority over Naloxone administration, with a focus on high-quality CPR (compressions plus ventilation). (Class I, LOE C-EO)

In October 2015, the guidelines were updated to add:

It may be reasonable to administer IM or IN Naloxone based on the possibility that the patient is not in cardiac arrest. (Class IIb, LOE C-EO).

I have had a couple calls this year where I could not feel a pulse in an apneic patient who I suspected of opioid overdose.

We initiated CPR. I had a narrow complex rhythm on the monitor. I gave Naloxone IM, and after several minutes, the patient regained a respiratory drive. We were able to feel pulses and so stopped CPR. In both cases, I suspect the patients simply had weak or hard to palpate pulses in the first place.

Bottom Line: Focus on good CPR and proper BLS/ALS care.   Give epi for cardiac arrest.  Give Naloxone for respiratory arrest. 

And as always, please follow your local medical control treatment protocols and guidelines.

***

For more on the controversies surrounding the use of naloxone in cardiac arrest, read the multiple and excellent columns by Rogue Medic

The Myth That Narcan Reverses Cardiac Arrest

Naloxone and Cardiac Arrest

***

Portions of this post appeared in a previous blog post. 

Cameras in Ambulances

 

They have installed cameras in our ambulance just behind the rear view mirror. The camera records both the traffic in front of the ambulance and inside the front cab of the ambulance. It does not record the passenger compartment, and it (supposedly) is only a video recording.  Audio would be illegal in our state.

The camera is programmed to record in the case of an accident or sudden deceleration or swerve. It can also turn on if the driver or front seat passenger hit a button on the device. The camera will capture 10 seconds before and 10 seconds after the incident. In normal function the camera displays a green light. It will turn red when activated.

If you get in an accident and the recording shows you were texting or talking on your cell phone, much less drinking a beer, then you will have to accept your fate.

If you are driving safely and a distracted driver swerves into you, then the recording will be to your benefit.

I have only set it off once so far.

We were driving back to the base after a twelve hour day. There was a car stopped in front of me, waiting to turn right, so I put my left turn signal on, and started to pull out into the lane. I saw in the distance in my side mirror a car suddenly speeding up to stop me from pulling out. I still pulled out as I had plenty of room. The other driver flashed his lights at me. I remarked to my partner how much I hated cars that did that -- speed up to stop you from changing lanes. She agreed. “Sometimes,” I said. “I’d just like to roll my window down and give them the  finger. And just say 'F- you! F-you, asshole!' But I can’t do that because I work for the company and we are a big traveling billboard.”

“Yes, we are,” she said, “A giant billboard.”

“Still,” I continued, as I pulled back into the right hand lane. “I just want to roll that window down and give them the bird. 'F-you buddy!'” We both laughed at the thought.

Just then the man accelerated past us, and then swerved right in front of me. I hit the breaks, but since we were now on a downhill slope, I had to keep my foot on the break a little harder to stop. And I did stop, well before coming close to his bumper.

The red light went on.

D'oh!

A supervisor played the tape back for my partner. “What were guys laughing about?” he wanted to know.

Good thing there was no audio as it likely may have missed the context of our conversation.  I wonder if lip-reading is admissible?

***

On a footnote, I recently read that there is a bill in the Maine legislature to require cameras in the passenger compartments of all ambulances.

Under the proposal, only medical control staff and law enforcement officials would be allowed to view the footage and tapes would be destroyed after three months. The purpose of the bill, according to its sponsor, would be to ensure that all patients were treated equally. It would protect EMS from unfounded complaints and would protect patients from poor medicine or untoward acts by EMS workers.

I don’t know if the bill has much chance of passing. Clearly there are privacy issues that would need to be clearly defined, but I suspect the day will come when cameras are a standard in the back of ambulances. I do believe the footage in most cases will be quite boring. On many calls, there will be a lot of tape of paramedics and EMTs sitting on the bench seat, typing on their computers, while carrying on small talk with their patients.

PTSD

 

I attended a critical incident stress debriefing (CISD) a few years ago. I thought I had been invited to an informal get-together of folks from another service who I had been on a upsetting call with the day before. Had I known it was a formal CSID debrief, I wouldn’t have gone, as I had always avoided them in the past. Not that CSIDs don’t help some people, they are just not for me.

I have been in EMS for thirty years now, and I have been on traumatic calls. This one ranked up there, but since I wasn’t the first medic in, I didn’t catch the brunt of it. For me the worst calls are not always those that make the news.  I take it hardest when my patient dies in my care, when I have to witness a sudden deterioration and  feel helpless to stop it or feel like maybe had I done things differently I could have possibly affected the outcome for the better. Other calls where the patient’s fate has already been settled before I arrive are less taxing to me than they used to be.  This was such a call.

Each of us processes trauma and stress differently. When I was new, it helped to have an experienced person (another medic) guide me through what I was feeling. In time I learned where to put these calls. It’s not like you don’t think about them  -- you wouldn’t be human if you didn’t -- but you soon understand what the job is, and you understand that tragedy and, in some cases evil, are a part of our world.

At this debriefing a team member told those assembled, “You gotta let it out, you gotta let it all out or it’ll eat you up inside.” I didn’t want to be disrespectful because I felt I was a guest at someone’s house, but I disagreed. If you have a way of dealing with trauma by yourself and it works for you, then that’s good. Go with it.  I found hearing what others had seen and felt on the call was more traumatizing to me than actually going through the call myself. Their details (a cell phone, music playing, a family member’s response) recalled details from past calls I had done. They triggered an explosion of what I had kept contained. When it was my turn to say what I found most vivid about this particular call, I passed. I didn’t want to burden someone else with the images that were in my memory of the call. I found in the next twenty-four hours, that little box where I kept past traumas had been ripped open and all these ghosts from the past swirled around me. I suddenly vividly remembered calls I had long ago forgotten. It took me two sleepless nights to put them back in their proper place.

I have friends who have gone through traumatic calls on a scale larger than my own -- calls that could shake a priest’s faith in God. They struggled with what they experienced. Some talked with peers, others sought professional help, still others went it alone.  Most found their peace.

I know peers who have found great consolation with service dogs (I will likely be writing about this topic soon). Others have gotten medical marijuana cards (although I suspect some of them just like to be able to smoke legal weed). Tell the doctor you are an EMT and have nightmares. That and a $100 fee get you a diagnosis of PTSD and a card you can present at the dispensary. While I enjoyed smoking in my youth, and sometimes long for those times, I am a father and a busy person, and just can’t see toking my evenings away. I don’t even drink beer much anymore, but when I did, I avoided it in troubled times because I always wanted to be clear minded as I sorted through what challenged me.

I know there are some members of our profession who will be broken, who will endure as long as they can, and then end up on the wrong end of the bottle or even the wrong end of their own gun.

I guess you have to ask yourself how you are dealing with what you have witnessed, and if you feel like you are having a hard time, then find someone you trust to talk to or seek professional help. There are people out there who will help, and there are methods you can be taught to help you deal with what you have been through. If you don’t feel like talking about it, don’t. If you do, then talk about it. You are not more or less of a person for seeking help.

If you see a brother or sister in EMS struggling, let them know you care. Most organizations have confidential employee helplines and have people trained to recognize who may be suffering. Some cases may be obvious, other too subtle to see.

Sometimes it not that big call that does it, it is a quiet long accumulation of common sights that leads to despair.  If you sense someone you know is down, if they seem incapable of joy, ask:

“Are you okay?”

Three simple words with great power. Don’t hesitate to use them, even if you know the response:

I am, appreciate your asking.

Be vigilant.

Stay safe out there, and at home.

Take care.