A Ravine in Winter

 

There is a picture in the Hartford Courant of Mark Jenkins talking with police officers looking as forlorn as I have ever seen him.  They stand next to yellow tape sectioning off an area of woods just off Park Terrace where down a small ravine a man has been found dead. The paper describes the crime scene as a homeless encampment but it is little more than a small clearing with a dirty mattress, a blanket over some branches as a tarpaulin and a hollowed out log.   Mark is the leader of the Hartford Harm Reduction Coalition. A former user, who went to rehab himself seventeen times, with the help of friends he found his way, and now has dedicated his life to harm reduction, which he describes as set of principles that recognizes the humanity of users and works to get them help or keep them safe until they are at a place in their lives where they are ready to stop using.

Harm Reduction

A couple months back, I got dispatched to this same place for an overdose.  Mark and two members of his organization, Jose and Bryan, were already there.  They had been on their way to work on the construction of their new walk-in center when they were flagged down.  They found a man cold and not breathing on the broken winter branches and mat of old heroin bags. They gave him naloxone and by my arrival, the man was breathing again.  He was just starting to rouse and was combative in his haze.  They helped us carry him up to our stretcher.  He was lucky someone has seen him and that Mark and his crew were driving by. In the hospital the man's core temperature was 90 degrees. 

Some days when I am working, I stop by the site.  A few weeks ago, after we'd pulled to the side of the road, I looked down the small ravine and saw a solitary man there.  From my vantage, I saw he had his arm outstretched and was injecting himself. In the summertime the clearing is completely hidden by greenery, but in winter, it is all grey and naked trees.  The man in jeans and a black shirt nevertheless blended in, as if in this same season, he were stripped himself of much of what he once was. I told my partner to drive on.  

I don’t know if the dead man is the same man I took to the hospital or the man I saw injecting himself in the cold grayness or someone else.  I do know that he is not the first to die in those woods.

123 Americans died of overdoses in Hartford in 2019. 17 have already died in 2020.

In Mark’s face you can see the burden of this war he is fighting against stigma, against convention and bureaucracy, against death, against time.

 

25 Years

 

I hit my twenty-fifth anniversary at work last month. Twenty-five years full time as a paramedic. I am sixty-one years old now and feeling the wear and tear, particularly in these last two years. I don’t sleep well at night. My hearing is shot. I need a stronger prescription for my reading glasses (which I also use for intubating and IVs). Last summer I suffered my first worker's injury to my back that has left me with a lingering weakness in my legs.  Fortunately  it is not bad enough that I can’t work, but it is bothersome nonetheless. I still carry all my gear up five flights of stairs. I don’t get to the top as quick as I used to and I am sure to use the railing on my way back down. I was sick for over a month this winter. I had the really bad cough that everyone seems to have. I worked through the first three weeks because that’s what we do in EMS, coughing up green phlegm and downing decongestants. My energy level just wasn’t there. I finally said, enough is enough. I’m not coming back until I am well. I laid in bed for two days, and then when I went back to work after a week out, I had a splitting headache and was getting short of breath toward the end of my shift, and so I took some more time off. Good thing, I had plenty of PTO.

On Friday when I came in to work I saw the boss (a young man I precepted) and told him I wanted to change my status to part-time. I managed to get some more hours added to my hospital EMS coordinator job so going part-time at my medic job was going to be necessary anyway eventually, but finally saying it out loud, it felt momentous. I’m not going to work Sundays anymore (unless I want to) and other than a few remaining shifts I am already scheduled for, no more getting up at four in the morning. I will still work twenty hours a week, but will just call in when they have shifts available (they always do) and work the hours I can that don’t conflict with my work, family, and trying to get healthy again life-style.

The boss said he was glad for me, and then gave me my twenty-five year plaque and pin, which had been sitting in the supervisor’s office. I took it and shook his hand. The plaque is in the back seat of my car now. Eventually I will just put it in a box in the garage along with my 10, 15, and 20 year plaques. Not that I don't appreciate it, I just don't display things like that.  I also get to choose a 25-year gift from a special catalog). I got a kitchen knife set for my 10th and 20th anniversaries, which I still have (9 knives for the 10th and 13 for the 20th). For the 15th I got a GPS that my wife lost. I am thinking about whether to get the 17 piece knife set, a digital smoker, or a snowblower. The snowblower would be great for snowy mornings, but if I am no longer getting up at 4, the need isn’t as pressing, plus with global warming, I shovel less and less each winter anyway.

When I went to punch in Friday, after I’d gotten my plaque and told the boss I was going part-time, I saw a flyer over the clock and a picture of a guy I’d gone to paramedic class with. I was 34 and he was 24 back then. Like me he worked 25 years for the same company but in another division. The paper said he had a medical emergency and passed away unexpectedly. He was just 52. Nice young man with a family. A good paramedic. Since we were in different divisions, I saw him infrequently, always at the hospital pushing a stretcher. We’d say hello by name, and then go on our ways.

On Friday I worked with Jerry, an old partner of mine, who’s been with the company almost as long as I have. We have a great time together, laughing most of the day. Riding with Jerry, it’s like we’re not even working, just two friends hanging out. During a downtime between calls, we ran through the list of all the people we’d worked with who had died over the years. It was a long one. Some of the people we struggled to remember their names.

I still love being a paramedic. I just know its time to take care of myself and my family first. Today, instead of sitting in the ambulance writing this, I am in the stands watching my twelve year old daughter warm up with her team on the basketball court. I am putting the computer down as the game is about to start.

***

Service Dogs for First Responders

 

A fellow paramedic here in Hartford, Greg Shovak runs a great educational program called EMS and PTSD – Learning from Combat Veterans to Understand PTSD.  I attended one of his sessions a few years ago and thought it was excellent.  I learned a lot of PTSD, and also had my first introduction to service dogs.

Here is his organization's facebook page, which has lots of great information:

EMS and PTSD

Service dogs are not just for combat veterans, but also for first responders.  Several of the medics I work with (including Greg) have them and they often bring them to CMEs.  Their dogs are awesome and that means something coming from me (see my dog history below).  I can see how the dogs bring them great comfort.

Greg has been a true leader in helping those in EMS recognize and seek help for their PTSD.

Here are a couple articles he recently wrote on PTSD, including one that mentions his own service dogs.

https://www.emstoday.com/emerging-voices-content/2018/12/makingstrides.html

https://www.emstoday.com/emerging-voices-content/2018/12/makingstrides2.html

The above photo pictures Greg with his dog, Petey. 

Here is an great article about service dogs all first responders should read:

K9s for Warriors – because Together We Stand

It is important to understand that service dogs are specially trained, and are different from therapy or regular dogs, although all dogs can provide needed companionship.

Difference Between Therapy Dogs and Service Dogs

***

Me, I am not a dog lover myself. I would much rather deal with a six foot eight three hundred pound crazed patient on PCP than walk within fifty feet of a pit bull. In Hartford, pit bulls are the official city pet. Once I climbed up a stairwell in a public housing complex only to come up to a landing to find myself eye to eye with a bone the size of a bear femur and sleeping next to it, a pit bull the size of a large wild board. I went back down the stairs very quietly. I don’t even like little chihuahuas, who are also popular in Hartford. Big dog, little dogs -- please lock your dogs up in the bathroom.  Please!

When I was a little boy I lived in Turkey (true story) where packs of wild dogs ran in the streets of Istanbul. Giving them biscuits and patting their snouts was not advised. When I was five and now living in America, a neighbor’s poodle came into our yard and sent me running. My older sister stamped her foot and yelled at the dog and the dog turned tail and fled. She laughed at me as I stood there behind a tree with a pounding heart. That summer on an Indian Guide trip, while riding my bike with other members of our tribe, a rogue German Shepard picked me out of the herd as if I were a baby wildebeest, leaping at me as I pedaled furiously.  His teeth sank into my butt, tearing my jeans and leaving a two large red abrasions. As if I weren’t traumatized enough, a few years later, a family with a German Shepard named Stormy moved onto our street. The owner, a large cruel man, kept the dog in a big cage in his garage. In evenings he would let Stormy out to run. Several times I was caught out on the street and Stormy would chase me down as I ran frantically for home. His smirking owner would command him to get away from me.

Later in my late twenties, my girlfriend had a runt dog named Elizabeth, who was the only dog who’s picture the local humane society put in the newspaper two weeks in a row seeking an owner to spare the dog from being put to sleep. She was an older dog by the time I met her. I learned to love “Bibs.” I would take her on walks and scratch her head which she loved. Sadly, she got tumors and started having seizures. After the seizures she would be full of energy. You could hold up a cookie over her head like a Seaworld trainer and she would leap up into the air to snatch it. She often got confused after a seizure and would escape and wander aimlessly down the street. I would have to chase after her and carry her home. My girlfriend finally had to take her to the vet to be put down, but that afternoon she came back with her on a leash. She couldn’t do it. A month later she went to the vet again, but this time returned alone. It was very sad.

Several years sago, I promised my daughter she could maybe have a dog when she turned ten. She just turned eleven and no dog yet, although she still wants one particularly after visiting with her cousin’s dog. Her older sisters had a dog about fifteen years ago, but their mother ended up being the one to take care of the dog until she finally gave it away. With our work schedules, I worry about who would take care of a dog, feeling like the burden might fall upon me. Right now I work 72 scheduled hours a week. Maybe when my schedule slows down, I might be able to take on a dog. My daughter and I are very close, but having gone through it before with the other daughters, I know she will soon drift away from me, and like Puff the Magic Dragon, I will be alone again. Maybe someday I will get a dog. When I was a kid, the Monkees had a song. “I’m Going to Buy Me a Dog...Cause I need a friend.” We go into the nursing homes and some of them have resident therapy pets. I see how happy the dogs make the older residents. Companionship is essential to life.  

I guess I could see myself having a dog someday.  I don't know what kind of shape life and EMS will have me in by then.  Maybe a service dog or maybe just a regular old man's best friend.  Either way, I am opening to the idea.

***

(Petey)

***

Here’s a link for a petition to require the VA to offer service dogs to veterans with PTSD.

Require the VA to provide service dogs to veterans in need

For many a service dog can mean the difference between life and death, between feeling a part of the world, and alone.

Stay safe out there.

***

Greg's second article mentions Patrick Lollar, a former medic with us, who is now a standup comedian in New York City.  He uses comedy to combat his PTSD.  Check out this great set!

 

 

 

Common Cardiac Arrest Mistakes: Amiodarone

 

You and another medic are on the scene of a cardiac arrest. You find the patient in ventricular fibrillation and immediately defibrillate him into a narrow complex rhythm. You have pulses back and while you take a blood pressure – 130/84, the other medic inserts an IV. The other medic then says to you, “Pass me the amiodarone.”

What do you do?

A. Pass it to him.
B. Say, “No.”
C. Say “Why?”

You go with C. The other medic says, “To give to the patient (Dummy!). He was in v-fib.”

You say, “No, it’s not indicated.”

Who’s right? You or the other medic.

It is amazing how many medics have different views on this question, and some of this depends on when they were trained and how well they have kept up on changing guidelines. It also depends on their local medical control and the protocols they operate under.

Here in Connecticut our state protocols for cardiac arrest call for amiodarone or lidocaine for patients “unresponsive to CPR, defibrillation, and vasopressor therapy.” There is no protocol that allows the administration of amiodarone or lidocaine for patient’s post ROSC unless they are either in VT with pulses or they were given amiodarone or lidocaine while in vfib/pulseless VT. In which case, the medic can consider an infusion.

A patient who is shocked out of vfib or pulseless VT without receiving an antiarrhythmic before hand should not be receiving an antiarrhythmic after obtaining ROSC.

The AHA guidelines are clear. Amiodarone or lidocaine are for refractory VF/pVT only.

The International Liaison Committee on Resuscitation (ILCOR) recently reviewed the use of antiarrhythmic drugs for the management of cardiac arrest and “the period immediately after return of spontaneous circulation (ROSC)” based on the most recent evidence.

Here are their recommendations:

We suggest the use of amiodarone or lidocaine in adults with shock-refractory VF/pVT.

The confidence in effect estimates is currently too low to support an ALS Task Force recommendation about the use of prophylactic antiarrhythmic drugs immediately after ROSC in adults with VF/pVT cardiac arrest.

You can read more here:

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary

Now, some may argue we shouldn't even be giving antiarythmics to patients in cardiac arrest.  They have very good arguments and good science behind them.  

Amiodarone vs. Lidocaine vs. Placebo 

Read Emergency Medicine Literature of Note:

Amiodarone, Lidocaine, or … Nothing

Read Rogue Medic:

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest

If you are going to use amiodarone, then you should at least be following the AHA and/or your medical protocols.

In Connecticut that means, only using amiodarone for VF or Pulesless VT “unresponsive to CPR, defibrillation, and vasopressor therapy.”

Coming Soon:

Bicarb in Cardiac Arrest

1200

 

1200 Dead.

In 2018 Connecticut overdose deaths dropped after six years of steady rises. Was it a plateau? Or just a pause in a grim climb? The first six months of 2019 hinted that the deaths might be be on the upward move again, but none of us were prepared for yesterday’s news from the Connecticut Medical Examiner’s Office.

1200.  An eighteen percent increase over 2018.

94% of the deaths involved opioids.

The dead ranged from 17 to 74.

The culprit: 

Fentanyl was present in 979 of the deaths (82%), its most ever, continuing its unremitting rise since 2012 when it was detected in only 12 deaths.

 

What’s the answer?

End the stigma. Treat drug users like we treat victims of heart disease, lung disease, diabetes. With compassion, love and evidenced based medical care.

Recognize addiction for what it is -- a chronic brain disease, not a character flaw.

Make rehab available to those who want it and make medication assisted therapy (MAT) methadone and buprenorphine available to all who want it.

For those who aren’t ready for rehab or MAT, bring them in from the cold, open drug overdose prevention sites where users can be in the presence of trained providers instead of forcing them to shoot up behind dumpsters, in park thicket and in locked public restrooms where we find them dead.

Make naloxone as widely available as possible and drill in the message, never use opioids alone.

Sue the pharmaceutical companies for their pivotal role in creating the epidemic (lying about the addictive qualities of their products and for producing massive quantities of painkillers even though they knew they were shipping vast amounts to distributors who were then flooding the black market with their products.

Use the money to fund a drug war against addiction.

Above all, be kind to those afflicted.

***

More from the Medical Examiner’s report:

Heroin was present in 387 of the deaths, and only present without fentanyl in 88 of the deaths.

Fentanyl was present in 393 of the 463 deaths that tested positive for cocaine.

Xylazine, a veterinary tranquilizer was present in 71 of the deaths versus none the year before.

Amphetamines or methamphetamines were present in 70 of the deaths, also the most ever, and a number rising in each of the last three years. Connecticut has largely been spared the meth epidemic, but it may just be a matter of time.

One-hundred twenty-three (123) of the deaths occurred in Hartford, the most of any city in the state.

***

Drug overdose deaths increased by nearly 20% in Connecticut in 2019, reaching a record-high 1,200

Press Releases

Calendar Years 2012-2019

Xylazine as a drug of abuse: Toxic effects to endothelial cells in combination with cocaine and heroin