COVID 19 and Race

 Nationwide, blacks make up 13% of the population and account for 23% of the deaths.  According to the COVID Tracking Project, through today 25,932 black lives have been lost to COVID-19.  The project says “black people are dying at a rate more than 1.5 times higher than their population share.”

The COVID Racial Data Tracker

In Connecticut blacks make up 10% of the population, but account 15% of the deaths.

State-by-State Dashboard

Why might that be?

Here are some reasons:

Blacks could more genetically susceptible to COVID-19.

Or, more likely it could be because black people in America are more likely to live in poverty, in more crowded living quarters, have higher risk of hypertension and diabetes, have poorer diets, less access to health care, and be less likely to have jobs that allow them to work from home and mitigate their risk of contact with carriers.

Certainly the reasons for the above have a lot to do with American history, politics, and long-standing discrimination and disadvantage.

We have lived too long as two Americas. 

As we battle COVID-19, both the disease and the economic consequences, we should strive to leave no one behind, and work to see that all Americans have equal access to health care, educational and economic opportunity, and to the hopes and aspirations of a better life.  One America.

Peace to all.

American Summer

 I originally posted this in August of 2006.

It’s been over ten years I’ve been working in the city. Driving around in the ambulance, you can see the changes. None of the book stores I used to stop at are still in business. The barbeque place in the north end where they sold cornbread muffins for twenty-five cents is gone. The Lion’s Den – the Jamaican vegetarian restaurant — where you could smell the marijuana smoke coming from the backroom when you went in to buy soy patties – burned to the ground and was demolished. One of the city hospitals closed. The nursing homes all have new names. People still shoot each other and do heroin and call the ambulance for dumb things. There are still a lot of drunks, but none of the old ones are left. We don’t respond in the south end anymore – another company does. The fire department is a first responder now instead of the police who rarely ever came in the first place. Instead of navy blue uniforms we wear light blue shirts. There are more medics on the road these days where before there were just a few of us. We never did transfers unless they were ALS; now transfers are a regular part of the day. I’m as apt to be doing a dialysis run as I am responding to a motor vehicle.

I‘m working with a guy who has been around as long as I have, and we are talking about how some girls who were pretty when we started are now on the heavy side, how some medics who were sparks are now burnt out, how some new stuff is good – like all the overtime — and some is bad – like how the out-of-town dispatchers don’t know the streets. We talk about how you can never rely on anything to stay the same. All you can do is try to do your job and treat your patients decently. The seasons come, the seasons go.

The afternoon is slow. We are posted in an area near the edge of town. Instead of posting on the specific street corner that represents the area we are covering, we are about a quarter of a mile away at the maintenance entrance of a park, right next to a small pond. It is a beautiful August day – blue sky, a slight cooling breeze. We shut the engine off. I open the door and stretch my legs out. My partner goes over and sits on a bench. We are the only ones there. Five minutes later we get a page. Effective immediately per the PD we are to move to the assigned area. We look around and don’t see anyone. I look at the maintenance building, at the windows to see if anyone on a phone is looking out at us. Someone obviously complained to the police about us being in the park.

We get in the ambulance and drive up the road to the posting location and park on the asphalt in the sun. The AC is running, but we are in an old car and the engine is really loud. I try to do the crossword puzzle in the morning paper, but it’s late in the week and as you get toward Friday, it gets much harder. I don’t make much progress.

We go on a couple calls. On a motor vehicle, as we arrive lights and sirens, the cops give us the cut sign. They say they canceled us – it just never made it through the dispatchers. Then we get the dispatch. We’re canceled.

Dispatch sends us over to Main Street for an ETOH. The man who called leans out from a third floor window under a flag of Puerto Rico and points across the street to the baseball field and says, “He’s over there under the tree. He drinks too much. You need to take him to detox.”

We get back in the ambulance and drive over to the field, get out walk along the tree-lined fence, until we come to the entrance, and then walk over to where we see a man in a Yankees tee-shirt sitting with three forty ounce beers. He’s a got a big grin on his face. He’s just cracked open the first one and has two full ones sticking out of a paper bag.

“What’s up?” I ask.

“Drinking beer in the park,” he says.

“You know why we’re here?”

“Cause I’m not supposed to drink in the park?”

“No, that’s not our business. We’re here to see if you’re okay, if you’d like to go to the hospital. Do you need detox?”

“No, I just want to drink my beer. Did my uncle call you?”

“Is he the guy in the third floor window?”

“Yeah. He kicked me out of his apartment. He drinks more beer than I do.”

“Well, just because he wants you to go to detox, we can’t take you against you will, but you realize, if you pass out, we can come and take you.”

“I understand.” He smiles. He sees we are no danger to him.

I’m looking around at the lush green field, the beautiful August day, the beer which is cold right from the store. I look at my partner and I know he’s thinking the same thing I am. “If we weren’t on the clock,” I say, “We’d love to join you. You have a good afternoon. Don’t outdo yourself, and if you ever aren’t feeling well and need to go to the hospital or want detox, just give us a call. And if you do pass out and your uncle calls, we’ll have to take you in. Understand?”

He smiles again, and extends his hand. “You guys are alright,” he says. “It’s a deal.”

We walk back to the ambulance, get in, and then drive back to the apartment building where we call up to the guy in the window. “We can’t take him,” I say. “It’s America. He’s alert and oriented. He’s got rights.”

The man, who we can see has a long-necked bottle of beer of his own in his hand, shrugs and thanks us for trying.

“He passes out, you call us back, and then we’ll come and get him.”

He waves, and sticks his head back inside.

I don’t know about my partner, but when I get home I have a few cold ones myself and sit out in my back yard and enjoy the summer evening.

Time passes. Sometimes you need to stop and enjoy the seasons.

Dragon Breath

 

“Rebound!  Get under the boards!  Use your butt! And rebound!”

I am next to the father of a girl on the team playing my daughter’s team.  He is wearing a mask, but it is under his chin and as he shouts at his poor daughter, I can see the spittle flying from his mouth.  The man next to him is also weaning a mask, but he pulls it down every time he yells at the ref.  “Travel!  That’s a travel!”

All the other members of the team’s fan contingent sitting in the stands nearby are wearing masks, but many of those masks are also on their chins or if they are over their mouths, they don’t cover their noses, and the parents pull them down to yell at their daughters or the refs.

I feel bad for the guy’s daughter.  She is the tallest and heaviest person on the court and she is doing her best, but only when she scores does she draw praise.

I am sure her father loves her, and loves watching her play, but I worry that he doesn’t recognize the seriousness of what is happening in the world.  Why wouldn’t he follow the rules and wear his mask properly rather than sending his dragon breath of possible COVID spittle into the air of this facility where sixty girls are playing basketball on three courts in a gym that is hot and not as well ventilated as the other gyms the girls have played in?

Maybe some people think the same of me, wondering why I allow my daughter to play at all in an indoor gym in this time of COVID.

The other gyms my daughter has played in have all followed strict protocols, but this one is crowded and hot and the mask wearing is half-assed and there are no temperature checks at the doors, and teams waiting to play next are allowed to congregate in the building instead of being held outside.

I am thrilled my daughter is getting to play again, and while COVID is very low in Connecticut now, there are hints of an uptick, and I have told her to enjoy each game as if it were her last because if COVID comes back or if anyone gets sick at any of these games, they are going to get shut down.  Or if the numbers come up and she is asked to play again in a gym like this, I will shut her down.  Still it will be a shame.

Sports adds immense value to life.  You need joy in life and sports bring my daughter great joy.  It all makes me wonder about the limits of risk.  I will continue to work as a paramedic and treat COVID patients and come home to my family.  I will let my daughter play sports as long as I believe it is safe and it brings her joy.  I won’t eat in a restaurant or get on an airplane or go to anyone’s house for a party.  I wear my mask when I am within six feet of anyone not in my immediate circle.  Other than going to the grocery store and taking my daughter to her practices and games, I stay in my own bubble as well as I can.

I don’t understand why everyone is not following the safety protocols.  I don’t understand why people don’t wear masks.  I don’t understand why a business that needs to stay open doesn’t take every precaution they can.  Ban the parents if you have to.  Let us watch online.  Better that than add risk.

I think in the end, there is an absence of education and understanding of the germ.  Many people don’t understand that masks save lives.  My daughter’s coach keeps them outside until the game starts.  He makes them wear masks unless they are in the game.  Everyone who comes off the court, has to sanitize their hands.  Game out over, out the door.

I hope her sports seasons continue.  I hope that no one gets sick.  But I am worried.

What if COVID stays with us forever like the common cold?

Will we close all sports down?  Will we play through it despite collateral damage?  Or will we find good safety protocols and stick to them?  

I am watching sports on TV now.  Breaking news.  The Florida Marlins baseball team, 14 of their players have tested positive for COVID and their game tonight has been cancelled.  The talking heads on TV are saying the major league baseball season is doomed.

Report: Marlins-Orioles game canceled due to possible COVID-19 outbreak

In another story, an NBA basketball player is let out of the bubble they have been keeping the players in to minimize risk to attend a funeral.  He is spotted that night in a strip club.

Lou Williams must quarantine for 10 days, will miss at least two games

People, wear your masks. Reduce risk wherever you can.  Be careful.  The dragon is still out there.

Much is in jeopardy.

Hidden Bias

 I don’t like having too many choices.  A few years ago, I wanted to get a bigger TV.  I just wanted to go into the store and come out with something in the 50-60 inch size.  I went into the store fully intending to buy a TV, yet I walked out of there with nothing.  Why? Because there were too many choices.  I could have made an easy choice if it was size alone, but the choices weren’t about size.  They were about features and gizmos and catch phrases for technology that I mostly didn’t understand.  This one had this and that one had that, and it was all too much for me to decide.  I ended up just giving my daughters my credit card and a price limit  and telling them to bring home something nice.

I needed a new dermatologist.  My aunt died of melanoma many years ago, so I am supposed to get an annual mole check.  I was going to one doctor for many years, but then he unexpectedly closed his practice, and I never got a new one.  The other day I noticed a new mole on my arm that wasn’t there before.  While it looked pretty innocuous, it spurred me to get back to having my annual checks.  To do so, I needed a new dermatologist.  I went to the hospital web site and there were almost twenty dermatologists to choose from.  Here’s where the problem came in. 

I would have been happy to take any one of them, but I had to choose one.  And it wasn’t a list of names, there were pictures.

I felt like I was suddenly part of a research experiment/focus group.  Who was most likely to be chosen (or not) and for what reason?  Which of their hands would I place my life in?

The older white man (Marcus Welby)   Should I take him as the trusted old time doctor or should I avoid him because he might be out of touch with the latest science and maybe behind his smile and good nature, be hiding a touch of dementia?

The middle aged Asian woman.  Should I choose here she might be super smart or should I avoid her because she might be harder to understand if she has a strong accent?

The young black doctor.  Should I take him because he may have overcome much to become a doctor or, is there a worry that he may be there only as a token?  Of all the doctors he is shockingly the only one from his race.

The young white man.  Should I take him because he may be up on all the latest info?  Or do I worry he is a rich kid who has everything handed to him on a silver platter and he may only have gotten into med school because his Daddy donated to the college hospital or is best friends with the Dean?

As each picture provoked multi responses in me, I wondered if I should just go "eeny, meeny, miny, moe?"

I ended up getting a referral from a doctor friend.  I called for the appointment without checking the name against the pictures.  I was asked if I minded being seen by a resident instead, and that was fine with me.

When I went for my appointment I was seen by both a resident and an attending, and I found them both very professional, and I was grateful for their time.  The mole indeed turned out to be innocuous.

Still the episode of reacting to the pictures troubled me because as much as I want to view everyone the same, the exercise brought out hidden biases, maybe biases that I may not act on, but ones that flashed into the control room of my brain, raising troubling questions.

It all made me wonder what people’s impressions are of me when I come through their door.  I am a very tall scraggly looking, long haired, mustached sixty-year-old white man?

Do I project experience?  Do they think I might have dementia?  Do I look kind?  Do they trust me with their lives?  Or do I scare them?  What biases do they hold toward me?

Hopefully, once I introduce myself and start caring for them, they feel okay about me being their provider.

Home Test

 

I participated in a research project this week, testing a home COVID antibody test. I had to do it while being watched via a zoom link by a study monitor, as well as answering a series of questions about the test.

Here’s how it went. The package came in the mail. After opening it, I placed all the components out on a prepared sheet. I ran my hands under warm water to get the blood circulating, then wiped my nondominant ring finger with an alcohol swab, and pricked myself with a lancet just like the ones we use to test a diabetic’s blood sugar. I hadn’t pricked myself in a long time. When we tell the patient it is like a little bee sting, that is a good description. I still feel it. They give me a little tube to collect the blood. More is needed than what you get to do a blood sugar. I had to milk my finger repeatedly to get enough blood to fill the tube. Next I held the tube over the test kit and dropped the blood into the specified collection hole. Then I added two drops of a buffer solution and waited 12 minutes. Just like a pregnancy test or fentanyl test strips, a line appears indicating the result. I took a picture of the test and uploaded it on the phone app. A doctor is supposed to contact me later with the results, although it was pretty easy to figure out for myself.

No antibodies.

The test was simple and easy.

I would buy a kit if they were on the market and I wanted to know if I had COVID antibodies.

Not Lost

 

Connecticut continues to have low rates of COVID-19.  Our state only has 56 patients in the entire state hospitalized with COVID, we are averaging only 2.2 new cases of COVID per day per 100,000 people.  Our testing rate is 0.8 % positive for a rolling ten day average, 0.6% over the last three days.  Our infection rate is 0.82.  (Anything less than 1 means the epidemic is dying). Our governor has put 32 states on our quarantine list, which requires those arriving from any of those “high risk” states to either produce a negative test result or quarantine for two weeks at home or risk a $2,000 fine.

To combat surging COVID-19 cases elsewhere, Connecticut requiring quarantine for travelers from 31 states

COVID ACT NOW Connecticut

Mask wearing is close to universal.  Here people scowl at those who wear masks improperly -- keeping the nose exposed.  Distancing is largely maintained.  This isn’t to say there aren’t violations or occasional large gatherings, but for the most part everyone here is with the program.  I have heard anecdotally that most new cases are patients recently returned from visiting states where corona is rampant.

While the major leaguers fret about the dangers of playing baseball, football or basketball for millions of dollars in the midst of a pandemic, my daughter, and many like her are back to playing competitive sports in our state.  The basketball has been both outdoors for practice and indoors for tournaments.  The two tournaments my daughter has played in have been at commercial facilities, and they have taken the precautions of limited access.  Either no parents at one tournament (we watched the game on the internet) or one parent per player at another.  Fans were distanced and all wore masks.  The referees even wore masks and carried hand whistles.  Teams played back to back games and new teams were only allowed in a facility when a prior team had exited.  The softball is outside, the girls maintain distance when not in the field.  Instead of being in the dugout, they spread out along the fence.  There is no high-fiving.  Life seems quite normal.  And we appreciate it, enjoying each day.  

Yesterday I swam in the town pool under the brilliant sunshine in 90 degree heat.  I was one of six who had reserved a lane for the fifty-minute time slot..  Each person is allowed to reserve three sessions a week.  It is not swimming everyday like I was used to, but it felt great.

There is still talk of us getting hit with a second wave in the fall when the weather cools and people are outdoors less, but I am hopeful that this period now is more than just the calm in the eye of the hurricane.  It seems to show that COVID can be beaten back and that life as once knew it is not forever lost.

Inadequate

 70,980 dead of drug overdoses in the United States in 2019.

This is according to provisional data newly released from the CDC.

The number represents both a record high and a 4.8 percent increase over 2018.

Connecticut’s death rate rose 17 percent during the same time period.

You can read the CDC report here:

Provisional Drug Overdose Death Counts

Connecticut’s fatal OD data for the first six months of 2020 should be available by the end of August.  Based on data I saw recently* about the first four months of 2020, Connecticut’s OD rate was up 24% over the same time period in 2019.

This upsurge (its way more than a tick) is not due to COVID because deaths were up 23% in January-February, while COVID didn’t hit until March.

Why the upsurge?

It could be the continued increase of fentanyl (present in 92.1 percent of deaths in February 2020 versus 79.7 in 2019), the addition of other adulterants such as xylazine (which was found in 40 deaths in the first four months versus only 10 in the same time period of 2019), or just the steady onslaught of stigma and a failed war on a drugs.

COVID-19 has killed 137,419 Americans this year alone, including 4,380 in Connecticut, and has been met with an unprecedented, deserved, and some would say still inadequate, response.  As far as fatal overdoses and the opioid epidemic, for all our good intentions, I think most would agree our national response has been, and continues to be, inadequate.

These are trying times.  What we do as a nation in the coming months and years to protect our most vulnerable, will be the true mark of our country's stature in the world.

*Department of Public Health Presentation for Alcohol and Drug Policy Council Virtual Meeting

6/16/2020

Bizarre Foods Hartford

 From 2012-2014, I kept up a blog called A Paramedic's Guide to Take out in Hartford.  I haven't updated it since then, but am considering doing so.  In the meantime, I came across this old entry called Bizarre Foods Hartford, and since all five restaurants are still operating (open for carryout), I thought I'd post it.

***

Okay Andrew Zimmer of the famous Travel Channel Bizarre Food show, you are challenged to come to Hartford and eat your heart out. Here in reverse order are my top five suggestions for Bizarre Foods Hartford.

5. Beef Lips Tacos

You can get these at El Serape, a Mexican place on Broad Street. It is best to order when leaving Hartford Hospital and hope you are not sent to cover Newington before you pick them up. Beef Lips Tacos are made from -- that's right -- cows lips. And believe it or not, they are delicious, with a very soft almost buttery texture. They go for $2 each, and are well worth it.

4. Morcilla, or Blood Sausage

You can get these at any Puerto Rican restaurant in town. Morcilla is made from pig's intenstines and cow blood. They are served hot, and I have to say they don't taste as bad as they sound, but I was unable to overcome the thought of what I was eating, and was only able to get down one bite. I gave the rest to a Hispanic EMT, who considering the dish a delicacy gobbled it down greedily. 

3. Pig's Head

Okay, you have to be in West Hartford to get this. You can get it from A. Dong Grocery on Shield Street, right by the office. What better way to celebrate the end of a shift than buying a six-pack of beer and a pig's head. You may need to call in advance to reserve your head.

2. Goat's Head Soup

Goat's Head soup, also known as "Mannish Water" is available on Fridays at SeaShore on Garden Street. It it made out of goat head meat and brains and lots of vegetables and maybe some dumplings added in. I love me some Jamaican soup, but this is not my favorite. It is however, a known aphrodisiac, so I am always sure to leave my cup empty.

And ta-da,

1. Cow Cod Soup

You can get this from Jahm Ske's on Albany Avenue on Saturdays. I must be frank with you, I have never tried it. (This picture is thus from the internet.) Cod is another word for penis. In other words, this is cow penis soup. Sorry, folks, I can't do it. Andrew Zimmer is likely a better man than I.

The Chair

 Last week, (due to medic vacations) the company put me into a volunteer town as the paid paramedic (on an ambulance staffed with volunteers) for my shifts. Many years ago, I worked three days a week in the same town in addition to three days of overtime in the city back in the days when overtime was like fruit on a tree in full harvest not COVID bare as it is today (declining call volumes mean no more OT for those who want it and no forced order ins for those who don’t.)

The volunteer town was a pretty good gig. I would punch in at six in the morning, check my gear and ambulance, then head to the bunk room where I laid my head down on a pillow and pulled a flannel blanket up to my neck, and with good fortune, I would sleep until 8 when the morning volunteer crew change occurred. I’d have breakfast and sit down at the computer and write, play on-line poker or just surf the internet. Every now and then the horn would blast and I’d have to do a call. Sure there were busy days where I didn’t see the “barn” until 6 in the evening, but they were not common. I did three or four calls on an average day, five or six on a busy and one to two on a slow one. Many were the days around noon, I’d get on my bike and ride around the industrial park. One day I rode 26 miles straight (well in a circle). The only thing keeping me from going longer was a sore butt and thirst, or of course the radio on my hip going off. But there was also the lure of the recliner. I’d get a cold drink, sit down in the chair, pull the lever and up the feet went. Hopefully the eyes would close until I’d get a tap on the shoulder that my evening relief had arrived, but inevitably, the horn would go off again. I’d curse and then head out to the ambulance.

The town had a large elderly population (both living at home and in the town’s five nursing homes). I did a lot of diabetics, a lot of asystole codes, and a ton of hip fractures. There were some high speed roads that produced some bad crashes, but overall, not a lot of trauma aside from self-inflicted.

Both days I worked last week were slow and I got a lot of computer time (alas no bike riding). I quickly remembered the old feeling I had that the longer I went without a call, the less I wanted to do a call, and when a call came, it came as an intrusion. I don’t want to be in that mindset. In the city, other than in the last half hour before crew change, I like constant calls. Constant calls make the day go by, they increase the chance I’ll do something really interesting, and I am doing what I am there for–to help people. Making matters worse for me last week was the new recliner in the TV room. This new one had buttons and drink holders. All that was missing was the massage, which it may have had (I may just not have hit the right combinations of dials).

In the volunteer town the most stress I felt all day was waiting for six o’clock when my relief came in. In the city, on a normal day, we are sent in a half hour before crew change. Sure there are late calls, but they usually come before you are sent in. In the volunteer town, until your relief’s car pulls into the parking lot, you are on the hook. Fifteen to six. Ten to six. Five to six. Please horn don’t go off. One to six. Then finally the car in the lot and you breathe a sigh of relief.

I don’t begrudge all the work I got done on my computer, as well as the rest time, but the older I get, the harder it is to get up out of a comfortable chair. I’d just as soon not get used to. This week I should be back in the city, back in the vehicle seat.

Don't Run. Call 911

The Greater Hartford Harm Reduction Coalition is passing out free wrist bands which say "Don't Run Call 911."  The bands also list their phone number 860-888-5931.  One of their harm reduction workers gave me a bag full of them to pass out.  Now after treating an overdose, and giving my harm reduction spiel -- Don't use alone, Have naloxone available, do a tester shot if buying a new batch or from a new dealer, don't mix opioids with benzos, call 911 at first sign of an overdose -- I hand out one of their colorful bracelets.  While we try to get everyone who has overdosed and been resuscitated with naloxone to go to the hospital, many who are now alert and oriented, exercise their right to refuse.  I know some systems are allowed to leave naloxone with refusal patients, friends and families-- I wish we could--but in the meantime, I have these bracelets to hand out.  It is a small gesture, but the number can be lifesaving.  At all hours of the day harm reduction workers will meet users in distress to help get them into rehab, give them naloxone or just clean needles.  (They also pass out face masks and information about COVID testing!)  The goal is to recognize where they are at along the continuum of substance use and try to keep them safe until they are ready for the next step.

Don't Run, Call 911. 

COVID ACT NOW-Infection Rates

 A friend of mine just told me about a COVID-19 tracking site that he checks daily.  There are so many COVID tracking sites out there, but this one is unique in that it tracks the infection rate.

COVID ACT NOW

The infection rate is critical because as long as it is below 1, meaning each person with COVID is passing it on to less than 1 person, or that 100 COVID patients are passing it along to less than 100 people, then we are winning.  When the rate climbs back above 1, then we need to take action to get it back under 1 or else the spread will continue to rise.

Here is Connecticut's chart, which shows a small uptick, but enough to get us back over 1.  Things have been going great here and we have been opening in a cautious manner.  The governor, has however, delayed phase 3 of our reopening, based not on what has been happening in Connecticut, but on the unbridled spread elsewhere.  I know I will be checking this chart daily.

 

Daily coronavirus updates: Positive cases, hospitalizations rise in Connecticut for third consecutive day

Medievil

I just had my second COVID-19 test.  This was part of a study of health care workers at my hospital to see how many front line providers might be infected.  It comes a little late as infections are way down here in Connecticut.  Our positive testing rate (not infection rate) is less than 1% and has been for some time.  Rates under 5% are considered good.

The nasal swab test is very unpleasant, but it is also fairly quick, or so I thought based on my first test early in June.  In that case, the swab was out of my left nostril and into and out of my right nostril before I could even complain.  Not so yesterday.

The tester went medieval on my nostrils, or should I say brain, because that swab goes feet deep it seems.  He didn't just go in.  He went way in and then probed around, swishing and swirling and making little circles like he was obsessive compulsive brushing his teeth.  I normally take most tests quite well and never flinch.  He had to tell me to stop moving my head.  I wanted to say, I'm not the one moving my head.  Your nasal swab in pounding me like it has a heavyweight boxing glove on the end.

Anyway, poor me.

I got the results back and I am once again negative, or according to the results, no COVID-19 detected.

My takeaway from this, after having experienced two different swabbers, I can see how technique could affect the outcome.  In the first case, the swabber might have missed some COVID sleeping comfortably up in the distance recesses of my nostrils untouched by the probing swab.  The second swabber might have found the COVID, but crushed the entire colony to death with his violent pounding.

As it is the false negative rate for the nasal swabs has been estimated at 20-30%.

Tests may miss more than 1 in 5 COVID-19 cases

How Accurate Are COVID-19 Tests? Many Factors Can Affect Sensitivity, Specificity of Test Results

Someday, this will all be over.  I hope. 

A Long Time

 

Prepare yourself.  COVID may be with us for a long time.  Think of it like its cousin, the common cold.  No vaccine for the common cold has ever been found despite its longstanding menace to the people of this earth.  True, many of the world’s brightest scientific minds and billions of dollars are at work now to find a vaccine for COVID-19--far more than ever tried to solve the common cold--but it guarantees nothing.  And even if a vaccine is found, it is likely to be in the words of COVID-19 CZAR Anthony Faucci, “finite.”  That means it will work for a limited time only.  Research continues to demonstrate that antibodies do not appear to be long lasting in those who have had COVID, particularly those who were asymptomatic.

Coronavirus expert says Americans will be wearing masks for ‘several years’

Coronavirus herd immunity may be 'unachievable' after study suggests antibodies disappear after weeks in some people

Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study

Dr. Fauci says coronavirus immunity may be ‘finite,’ duration remains uncertain

While not enough time has passed to test whether people can be reinfected if antibodies don't last, it seems entirely possible that you could catch COVID again just like get the common cold again.  Maybe sometimes you are asymptomatic or have mild symptoms, but particularly as you age, the odds of getting a savage case of COVID might likely increase.  The maskless bar partiers who call COVID-19, "the boomer remover" may end up themselves some day in a nursing home at high risk for not just the flu, but for the germ they mocked -- COVID-19.  

Morbid ‘boomer remover’ coronavirus meme only makes millennials seem more awful

There is still much to be learned about this devious germ, but we may need to start facing this unpleasant fact that it may not go anywhere. 

We may just have to learn to live with COVID, moderating our society to reduce risk, while still maintaining some semblance of our larger society.  Wear masks, distance when possible, and redesign our society (as we have already started to) with zoom meetings, staggered school schedules, curbside pickups and backyard vacations.

Very few people are taking the possibility that COVID is going last beyond another year seriously.  This is particularly true in the sports world where many players are choosing to sit out the remainder of their shortened seasons out of concern for health risks to themselves and their families.  That’s fair.  No one should have to increase their risk, but I wonder:  If the corona risk will be the same next year and the year after that, if these players feeling will change?  If COVID is going to be with us for the next five years or more, will players give up five years or more of their careers, not to mention million dollar salaries that may never come to them again.  Will they abandon who they are as professional athletes.

Mike Trout unsure he’ll play in 2020 because he’s ‘very concerned’ about COVID-19

Everyday people in EMS, hospitals, nursing homes and other health care professions go to work for a lot less money than pro athletes, and they endure much more risk than their sports heroes.  They do it because they love their jobs, they feel an obligation to others, and, for many, they also need the paycheck.  So do grocery store clerks, corrections officers, bus drivers, fast food workers and all the others who are keeping our society running.

I am a paramedic.  I don't want to stop being who I am.

We all make our choices.  We make the world and the society we want.  We live the lives we want.  I say embrace the world.  Seize the day.  Just be safe about it.

As a paramedic, that means, using PPE when appropriate and disinfecting the equipment between runs.  It means stripping in the laundry room when I get home, washing all my clothes on high heat, and walking right up to the shower and scrubbing myself clean.  

As a parent, it means teaching my children the importance of physical distancing and wearing a mask.  It means making certain the situations they enter are as safe as possible.

As a citizen of the world, it means showing appreciation for the lives of all, thanking the grocery store worker, giving a bigger tip to the waitress, valuing the lives of our oldest citizens and those most at most risk, by doing my part to keep the curve flat.

Enjoy each day and appreciate each moment.  Don't let COVID-19 change who we are.

 

 

EMS Books

 Worried about COVID-19?  Stay at home, read a book.

Jim Bollenbacher's new book, Molly, Mushrooms and Mayhem which I recently reviewed,  is now available on Amazon.

While you are at it, here are some other great EMS books to check out.

Lights and Sirens: The Education of a Paramedic by Kevin Grange published by Berkley. This a great account of a young man going through paramedic school. I reviewed it in more detail in this post:

Lights and Sirens

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Michael Morse first two excellent books Rescuing Providence and Rescue 1 Responding are combined into one book and published by Post Hill Press and distributed by Simon and Shuster.  I reviewed Rescue 1 Responding in this post:

Responding

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A Thousand Naked Strangers: A Paramedic's Wild Ride to the Edge and Back by Kevin Hazzard published by Scribner. This is also a tremendously well written book covering the EMS career of an Atlanta, Georgia paramedic from eager EMT to eventual burn out and fade away nearly a decade later.

***

Kelly Grayson's En Route is a great read by the author of the Ambulance Driver Files.

Grayson is an EMS Mark Twain -- a gifted humorist who packs a serious punch. He does a great job of describing what it is like to be in EMS -- the good and the bad, the high points and the lows.  

***

Turning to EMS Fiction, a little known, but excellent book is Black Flies by Shannon Burke, which retells Joseph Conrad's Heart of Darkness with EMS as the background.

I reviewed this book many years ago on this blog:

Black Flies Review

***

Lastly, I will throw in a pitch for my EMS fiction.

Diamond in the Rough tells the story of a young EMT's wayward journey through EMS. It takes place in Hartford in the similar setting to my first novel, Mortal Men: Paramedics on the Streets of Hartford.  The book has caused some controversy because the EMT narrator is a thief, who steals from his patients.  He, of course, eventually pays the price for his actions, but he does, despite his crimes, manage to find some redemption and a path toward grace.  After writing two nonfiction books about EMS in Hartford, I have turned to fiction because it offers a freer reign to explore the world of EMS and tell atypical stories.  

You can read sample chapters of Diamond in the Rough here:

Anthropophagi

Temptation to Steal

 

Mortal Men is a more traditional story.  Paramedic Troy Johnson battles trauma and sickness on the streets of Hartford, Connecticut. When a fellow medic is shot to death responding to a 911 call, a grief-stricken Troy vows to avenge the death, while struggling to come to grips with his own mortality.

 

Superspreaders

 

Recently in the New York Times there was article that suggested “Most People with Coronavirus Won’t Spread it. Why Do a Few Infect Many?"

Covid, it seems, is like a forest fire that can simmer and then sudden flash over.  While many diseases have a steady rate of infection (each person passes it on to two or three more), COVID seems different, It appears dependent not on the mass of victims to spread the disease,but on a few super spreaders.  10 percent of the positive seem to be infecting 80 percent of the subsequent positives. How is this possible?

In the right situations, the article explains, one person can become a “virus chimney”  All it takes is:

1. The right day (likely a few days after infection)
2. The right place (a crowded bar?  A church choir?  A meat packing plant?  A nursing home.
3. An extended period of time where that superspreader is in contact with a group of people.

This is why we all need to wear masks and also to avoid contained spaces for extended periods of time.  We need to do this not only to help avoid corona ourselves, but to avoid being a virus chimney infecting others before we even know we have it.

Here is a great discussion of how masks work.  It contains a great line.  

My mask protects you.  Your mask protects me.

https://youtu.be/BA2BOT3A70w

Stay Safe.

Forced Sedation

 

Interesting article on NBC news about the use of ketamine for sedating patients in police custody. 

Elijah McClain was injected with ketamine while handcuffed.  Some medical experts worry about its use during police calls.

The reporter centers the story around the tragic case of Elijah McClain, who was apparently walking down the street, wearing a face mask and listening to headphones when a 911 caller said he was acting strangely.  The police stopped him and ended up taking him down with a chokehold.  He said he couldn’t breathe and he vomited.  EMS came.  The officers told them he was on something and was exhibiting inhuman strength.  The medics gave Elijah a large dose of ketamine, and shortly after he was in cardiac arrest.  He was resuscitated, but suffered a brain injury and was unplugged.

In light of today’s awareness of cases of brutality, this case has aroused considerable attention and controversy.

The article seems to take the positions that 1) people should not be injected with a sedative during a police action and 2)  they should not be injected against their will.

The reporter talks to two college neuroscientists, a pharmacy professor and two lawyers including  someone from the American Civil Liberties Union.  He doesn't talk to an emergency physician or a paramedic.  An ED doctor or a paramedic would have likely provided insight into the real world conditions where these cases play out.

Here is my take on it.  First, I just want to say, this was a tragic case that should never have happened.  Just because someone is acting strangely or may be mentally ill (unless they are bothering someone or are observed committing a crime), they probably shouldn’t be physically restrained.  Where I work in Hartford there are a lot of people who act strangely, but once you know them, you learn they are not acting strangely for themselves.  There are just a lot of strange people out there, and not everyone should be held to the normal person standard. 

In this blog post, I only want to address why a paramedic would give someone ketamine or a sedative like Versed or ativan (benzodiazepines) against their will.  (Note: I do it quite frequently.)  We don’t carry ketamine in my section of Hartford, but as an EMS clinical coordinator that oversees several EMS services, we approve ketamine for use in certain circumstances, including to sedate violent patients. 

Our statewide paramedic protocols call for a number of measures to calm someone down and deescalate scenes.  It is not uncommon for us to respond to a violent EDP (emotionally disturbed person).  In many cases, the patient may be on drugs such as PCP and are resisting efforts. They may be naked in the middle of winter walking down the street.  (PCP makes people hot and it is quite common to have them disrobing in public). They may be smashing windows or merely threatening others.  I have had such people jump out of open windows.  They may also be schizophrenic, off their meds and talking about killing themselves or others.  If they are just plain crazy, standing on a street corner talking to themselves, as long as they know where they are, and have no intention of hurting themselves or others, we leave them alone.

Patients may only be restrained under the following indications:

Any patient who exhibits an altered mental status and may harm himself, herself, or others or interfere with their own care may be restrained to prevent injury to the patient or crew. Restraining must be performed in a humane manner and used only as a last resort.

We are authorized to do both physical and chemical restraint.  if someone fights against the physical restraints, I will chemically restrain them.

Continued patient struggling against restraints may lead to hyperkalemia, rhabdomyolysis, and/or cardiac arrest, chemical restraint may be necessary to prevent continued forceful struggling by the patient.

When I arrive on scene, I try to talk to the person, who the police may be holding down, sometimes in handcuffs, sometimes not.  If the person is alert and oriented and can carry on a normal conversation, I will ask the officers to let them up and take off their handcuffs.  If they are still resisting and are out of their minds, I will sedate them per out protocols.  The sedation works wonders.  It takes a few minutes to work, and I will urge everyone on scene to resist agitating them further, and let the medicine take hold.  I get them on the stretcher, we take the cuffs off and they are often sleeping like babies by the time we arrive at the hospital.

Paramedics do not medicate at the request of police.  Paramedics medicate based on their own medical guidelines to protect the patient and others from injury.  If a paramedic medicates a person, they are not transported to the jail, but to the hospital where they receive full emergency evaluation and care.

I try to put myself in the situation of responding to this particular case.  If I show up and if police are fighting with a man and they tell me he is on something and is showing extra human strength I am inclined to believe them (provided their description seems to match what is occurring in front of my eyes) and I would be inclined to sedate the patient if it appeared what the police were saying was true.  

As far as the excessive dose Elijah McClain received, I will say it is not always easy to properly estimate a patient’s weight or age in a chaotic setting.  We can’t have them step up on a scale as they might in a doctor’s office.  The fact that they estimated his weight at 220 pounds is curious because 220 pounds is 100 kilograms, which makes estimating the dose of ketamine much easier than if a patient weighed less.  At 5 mg per kg, the dose would be 500 mg.  Easy math to do in the head.  If the patient weighs 140 pounds, you would have to do the math  140 divided by 2.2 equals 63.6 kilograms.  Then 5 X 63.6 gives you a dose of 318 milligrams, about 2/3s of what he actually received.  A bit more complicated math, harder to do in your head than with the 220 pound/100 kilogram patient.

Maybe EMS should be more cautious of the story they receive when they arrive, but I can say based on experience, when the police say that the patient is violent and has superhuman strength, that is usually the case.  I have seen small women on PCP throw large officers off themselves.  I have seen police officers have the s kicked out of them, all the while employing only defensive tactics against people to avoid hurting them.  I have also seen officers respond back with what I might consider excessive counterattack.  The point is there are many mentally ill patients who are violent and there are a lot of drugged out patients who are also violent.  Sedating them is better than wrestling them or having someone, patient or medical worker, get hurt.  

As far as dosing, EMS needs to improve its weight estimating abilities, and should probably err on underestimating, particularly with a drug such as ketamine.

 

More Opioid Deaths?

 

Is the COVID epidemic causing increased opioid overdose deaths? No one knows for certain, but the head of the White House Office of Drug Policy is speculating that it has, citing increased death statistics from a few states such as Kentucky.

Pandemic unleashes a spike in overdose deaths

Here in Connecticut we won’t have an official answer until the Connecticut Medical Examiner’s Office releases its first six months of 2020 data (likely at the end of August).

I am involved with a statewide SWORD program that tracks EMS reported opioid overdoses.  Unfortunately, this program under reports fatal overdose deaths.  There are several reasons:

1. EMS compliance with reporting is estimated to be only 70%.
2. EMS often cannot ascribe the cause of a death to an overdose lacking eyewitness accounts of visible paraphernalia on scene.  (Example --A fifty year old lying dead in bed with rigor mortis and dependent lividity could have died from any number of causes from a heart attack to sniffing a bag of heroin that was either flushed down the toilet or removed from the scene by a friend prior to EMS arrival).
3. Some EMS reported nonfatal overdoses turn into fatal overdoses after the patient is delivered to the emergency department.

Based on the last four months of 2019 and the first four months of 2020, the SWORD statistics show roughly the same number of fatal overdoses.  April had the highest number of fatal overdoses for the first six months of 2020, but deaths reverted to the mean in May and June. 

It is hard to know for certain if fatalities are increasing because of COVID when you lack year to year monthly comparisons as well as a full understanding of all the factors (strength of supply, for instance) that could be at play.

The worry with COVID-19 is that increased overdoses could be caused by loneliness, isolation, decreased access to services, and possibly changes in the drug supply causing users to find unfamiliar dealers.

From the anecdotal perspective of the paramedic on the street, I can’t say there are more or less deaths.  There are still too many.  I did three presumptions in the last month, one in a port-o-potty, on a mattress in a vacant apartment, and one in a halfway house where the victim still had the needle in his arm.  All there were long dead when I got there.

I worked the city yesterday in the fly car, and while there were no fatals when I was on, I still responded to six overdoses (seven patients) in ten hours.  Three were opioid-related (two heroin--both received bystander narcan!, one unknown opioid), one was PCP (two patients on PCP at same call), one was cocaine, and one was vodka.  Now, yesterday was a Friday of a holiday weekend, shortly after the first of the month so there were plenty of reasons to expect a busy day beyond people trying to escape the COVID blues.

My friends on Park Street say there is no shortage of supply, and that prices have actually dropped from $30-35 for a bundle of ten bags to $25.  Is that because it has been harder for people to get to Park Street to buy their drugs because of lockdowns?  Are people short on cash (and unable to afford drugs) because they’ve lost their jobs? Not that losing a job has been a hindrance to people finding drugs.  Are dealers are having to drop their prices to get rid of excess supply?  Or maybe more drugs are getting through?  

All I know is there has been no let up in the dispatches for overdoses.

COVID-19 has killed many Americans both directly and indirectly.

Hopefully, this crisis is bringing to light the holes in our health care system, and will move us closer to becoming a country with a health care system that leaves no one behind.

Happy July 4th!

Golden Hour of Trauma

 R. Adams Cowley, the founder of Maryland's well-known Shock Trauma hospital in downtown Baltimore, famously said:

"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."

The Merriam-Webster On-Line dictionary defines "golden hour" as "the hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective."

The 2nd edition of the Prehospital Trauma Life Support said "The critical trauma patient has only 60 minutes to reach definitive surgical care or the odds of a successful recovery diminish dramatically."

(It is my guess that this is no longer in the current edition.)

The following quotes are from a 2001 Academic Emergency Medicine journal article:

"The Golden Hour: Scientific Fact or Medical Urban Legend?"

“The golden hour justifies much of our current trauma system...scoop and run, aeromedical transport, and trauma center designations with trauma teams in place are, in part, predicated on the idea that time is a critical factor in the management of injured patients....While it seems intuitive that less time is better for trauma patients, there are risks and costs involved in attempting to deliver patients to trauma centers within an hour...These may be justified if there is a benefit, but may not be if there is no proven benefit or if the benefit applies only to certain circumstances.”

In the article they researched Cowley and any mention of the golden hour. What they found was articles referencing articles that referenced articles that had no reference.

A text on trauma edited by Cowley contains a chapter authored by Shakar, which discusses “Cowley’s Golden Hour,” referencing a 1976 Cowley article.

“The 1976 article …describes Maryland’s trauma system and states that the first 60 minutes after an injury determines a patient’s resulting mortality.” It references a Cowley paper of 1975.

“1975 Cowley article states ‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’ but no data or reference is provided.”

They they looked at the scientific evidence about time and trauma. They found research studies both supporting a link and not supporting a link. As a rule the articles had poor quality, selection bias, small samples, and uncontrolled variables.

These were their conclusions:

“Our search into the background of this term yielded little scientific evidence to support it.”

“There are no large, well-controlled studies in the civilian population that either strongly support or refute the idea that faster is universally better in trauma care.”

“The intuitive nature of the concept and the prestige of those who originally expressed it resulted in its widespread application and acceptance.”

Which leads me back to a story I heard many years ago about the origins of the golden hour. Cowley, trying to win support for a the shock trauma hospital and what would become Maryland's elite helicopter program that would fly trauma victims from all over the state to the Baltimore hospital, determined with a helicopter any trauma victim in the state could reach the hospital in 60 minutes, thus "the Golden Hour."

Whether that story is true or not, I don't know. I do know there is nothing magic about 60 minutes. True some few may only have sixty minutes, but some have only forty, some five, and some none at all, while others may have two hours, two days or a lifetime.

Prehospital people need to look at each patient individually, weigh the risks (lights and sirens versus with traffic, helicopter versus ground), use their best judgment and common sense on a case by case basis. Err on the side of the patient. When in doubt contact medical control.

Clearly the more critical a patient the less time they have. Some patients truly need scoop and run. Ten minutes scene time won't cut it for them, many others may benefit by a slower, safer pace.

Promoting a definite time, not supported by evidence, serves no one.

***

A version of this post first appeared on this blog in 2009.

Yet To Come

 

My daughter had her first softball game of the summer yesterday. It was the first time she wore a uniform since her basketball team's playoff run was stopped in March with the first Corona cancellations.  Last night they got mercied 17-5 but it was a beautiful night and she got two hits. They were supposed to play again tonight, but a thunderstorm came up and drenched the fields. Afterward there was a gorgeous rainbow, but with more rain on the way, they called the game.

We came home and had dinner. Earlier that afternoon, I stopped at Bear’s Smokehouse and picked up our local “farm share” along with two pounds of smoked burnt ends. Every Tuesday we pick up a bag of fresh picked farm products. Tonight they had a head of butter lettuce, peapods, zucchini, mint and fresh picked strawberries, juicy berries that actually taste like strawberries not the bland flavor the fat pretty-looking grocery store ones have.

After dinner I lay down and read some news stories about COVID on my computer. Connecticut dropped under 100 hospitalized cases and their positive test rate was its lowest ever at 0.7%.

Daily coronavirus updates: Connecticut hits largest number of COVID-19 tests in a single day, lowest rate of positivity to date

Outside the state, COVID-19 is growing crazy, particularly in places like Florida, Texas, Arizona and California, many setting record highs. Dr. Faucci says if we don’t get it under control we could see 100,000 new cases a day. The World Health Organization says the worst is yet to come. People are still fighting over wearing masks. The governors of many states have said they won’t lock down again even though their states are on fire.

Here in Connecticut, our governor just added more states to the list of states with restricted travel to Connecticut. Anyone coming into Connecticut from California, Georgia, Iowa, Idaho, Louisiana, Mississippi, Nevada, Tennessee, Alabama, Arkansas, Arizona, Florida, North Carolina, South Carolina, Texas, and Utah must quarantine for 14 days after their arrival here or obtain a negative COVID test within 72 hours.

We knocked COVID down here, but I’m back to the old feeling I had in our earliest days, looking up to the hilltops, which are now empty, waiting for the enemy to appear again against the sky, and bring death down upon us.

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LA doctor on coronavirus surge: 'There's going to be a lot of death coming'

'The worst is yet to come,' WHO warns about the pandemic