Assassin

 

Connecticut saw its COVID positivity rate jump to over 6% last Thursday.  Our seven day average remains 3% for now.  Cases, hospitalizations and deaths are all up.  The flat line we enjoyed this summer has turned decidedly up and threatens to go parabolic.

The last three shifts I have worked I have done cardiac arrests.  All have been elderly who were somewhat independent, but with many comorbid conditions.  They all felt ill in the recent days.  All were connected to areas where there were known COVID cases.  None were tested for COVID.  Could these be independent deaths or were they the work of the greatest serial assassin of the last 100 years?  Will they be counted eventually in the COVID numbers or will they just appear in the “excess deaths” category?  It has already been estimated that there have been 300,000 excess deaths in America this year, meaning 300,000 more people than would have been expected to die in a normal year, are gone from us.

Amid pandemic, U.S. has seen 300,000 ‘excess deaths,’ with highest rates among people of color

As we move into what is predicted to be a harsh and dark winter in terms of the COVID pandemic, I worry about my fellow health care workers.  The fatigue is taking its toll.  In early days, once we had the PPE, everyone dutifully put it on despite its difficulties.  Now, I am noticing some responders tend to forego the extra gear.  It is one thing to gown up in a hospital room, where fresh supplies are stacked outside the door, the room is well lit and temperature controlled and the patient is on well positioned hospital bed, it is another to climb four flights of stairs, carrying heavy gear and find a patient on the floor in a tight hot bathroom with no lighting, lying in diarrhea and vomit.  Your gowns rip, trying to see through a face shield is like trying to drive in the rain with a broken defroster, and a N95 with a surgical mask over it doesn’t always allow all the oxygen you need in a dusty, stinking apartment.

I am on my stomach intubating, staring down the throat of a still warm body, looking at the vocal chords.  COVID is invisible, but I imagine him there behind the folds, taunting me, giving me double barreled middle fingers, then unleashing a dragon’s breath torrent of viral load, a hot water cannon of death and sickness that fills the room and our every breath as we do our best with no success to bring back his latest victim.

Narcania

 

There is a cartoon hero named Narcania created by the same guy who wrote Lil’Dope Fiend Overdose Prevention Guide.  In the mini comix, Narcania rescues people who have overdosed and gives them new life.  As one character who has been resuscitated remarks, “I don’t know if there is anything worth living for, but at least now, I’ll get to find out!”

In San Francisco there is a Narcania mural, Narcania vs. Death proudly painted in an alley.

In 2017 I wrote about Narcan Man, the mysterious person or force who seemed to always arrive and be gone before us, leaving only an empty vial of narcan and sometimes a confused, or vomiting person at the spot where we were dispatched for the overdose.  I imagined a man with bandoliers of Narcan and a gold tooth who roamed the metropolis, keeping people safe, and then disappearing into the mist.  Who was that man?!

I believe I have finally met the real life Narcania, the female Narcan Man.

Her name is Carrie.  She is a smallish woman in her late twenties, whose face shows both the promise of her youth and years of hard living.  Her voice is gravelly from cigarettes, and her eyes are hardened blue grey.  I’ve seen her walking Park Street and I’ve seen her helping out at the work harm reduction van.  And most recently I've seen her at a number of overdose scenes, where she stands to the side and disappears once we arrive.  I know her well enough now to call her by name and to chat a little.  One of these days I want to talk with her at length and learn her true story rather than one I might imagine.  This time  she was walking through the park ravine when she came across a man half hidden by a pile of logs.  He was unresponsive and cyanotic with agonal breathing.   She hit him with 2 mg of Narcan in the leg with her autoinjector and gave him some good hard shakes until he came around.  When she saw it was me getting out of the paramedic vehicle, after I’d driven down a dirt road and across a field to get to the OD site, she stayed.  The man didn’t want to go to the hospital, but she was able to convince him to go.  I let her do the talking because I knew he'd be more apt to listen to her than me.  While I walked him to the arriving ambulance, she gathered the belongings he had left and brought them to him.  Once he was loaded in the back of the ambulance, I turned around to say goodbye to Carrie, but she was already walking across the field.  “If she hadn’t found him, he would have been dead,” I said aloud.  I waved to her, and she gave me a little salute in return as if she were a cowboy and was tipping her hat to the townspeople as she rode off into the sunset.

“Who’s that girl?” One of the firemen asked me.

“That,” I said.  “That there little woman is Narcania!”

“Huh,” he said.

“I read about her in the comix!”

The Drumming

 

“That’s not unexpected, but it still wakes you up like a cold shower,” Lamont said about the rising number of positive tests, which suggest that the virus is spreading more quickly.

COVID cases have increased steadily in Connecticut since early September.  Nearly every day, the Governor’s response has been, “That’s not unexpected.”   He has often added, it bears watching.

Daily coronavirus updates: Connecticut’s positivity rate hits 4.1% and hospitalizations near 300; Lamont urges municipalities to enforce pandemic rules

I have been watching it.  So has the web site COVIDexitstrategy.org, which now lists Connecticut as on the states where COVID is in “Uncontrolled spread.”

https://www.covidexitstrategy.org/

I know the governor has done his best to walk the fine line between keeping the state open and keeping it safe, but we all need to pay attention to what is happening in the world.

Cases are skyrocketing. 500,000 new cases this week alone in the US. 

We have 40 states and 2 territories on our state’s quarantine list, meaning anyone coming in to Connecticut from one of those states has to either quarantine for 14 days or produce a negative test.  The sad thing is if Connecticut were another state we would be on our own quarantine list.

Nursing homes in our state were ravaged by corona when it first hit last spring.  8 have already died in a local nursing home since this second wave has hit, and each day there are reports of more outbreaks.

Connecticut orders mandatory testing of all nursing home staff in hopes of staving off outbreaks, deaths as COVID-19 cases climb

Last night in the World Series a baseball player was pulled out of the game in the 8^th inning when his COVID test came back positive.  Word is he had had an inconclusive test the day before so was retested and the retest confirmed he was positive.  He was ordered to self-isolate, but when his team won the series, he was seen running maskless on the field.

Why the hell did MLB allow Justin Turner to celebrate with the Dodgers after being Covid positive?

How the Dodgers' World Series Celebration Became a Possible COVID-19 Superspreading Event

I get it that people are tired of this pandemic and want to live their best lives.  I want to, too, and I think we can, but at some point we have to recognize the germ for what it is – a killer that targets our weakest and most vulnerable.

How hard is it to wear a mask?

How hard is it to isolate when you know have COVID and are at risk of spreading it to others?  This is not just another case of someone possibly having COVID, this is a confirmed positive case.

Can you not see that the spread of the germ from one to the next will ultimately bring another soul to a scene where a medical person – paramedic like me or a doctor-- stands over them, closes their vacated eyes and calls the time? 

Hear the drumming.  Another dead American in the U.S.A.

A Man Must Carry On

 

In the summer of 1977, when I was 18, my best friend Brad and I drove 1400 miles crisscrossing the country in an old Oldsmobile Cutlass.  We had no plan other than to see America.  We started off in New England, headed to Washington D.C. and then down through the Blue Ridge, Virginia, North Carolina.  We jutted back out to the coast to Charleston, South Carolina,  where we body surfed in the ocean and swam among porpoises.  We went down to Statesboro, Georgia, where we drank in a juke joint and ended up watching two local heroes duel in a street race.  We crossed the Florida panhandle, went through Alabama and Mississippi.  In New Orleans, a Louisiana lawman with mirrored sunglasses threatened to lock up for sleeping in a park.  We drove clear across Texas, with a stop in Juarez, Mexico where we bought colorful rugs and switchblade knives. At nights we slept in the car, sometimes paying $5 to stay at a KOA campground so we could use the showers.  Once a week we splurged on a motel.  We headed west across New Mexico and stood on a corner in Winslow, Arizona.  We hung out with hippie chicks at Mission Beach in San Diego, and then drove up Highway 1 to San Francisco where we spent a night drinking wine in an alley off Mission Street.  We headed back north through the redwood forests, and then said goodbye to the Pacific on a misty driftwood beach in Washington state, before headed back across the Rockies  and then east through Wyoming where we bought cowboy hats during the Frontier Days rodeo.  We crossed the Badlands, and then stopped in Milwaukee to visit the breweries before heading home in one last straight shot all across Middle America’s fields of waving grain.

Early on in our trip, we had installed a cassette player in the car and bought five cassette tapes.  Marshall Tucker (Fire on the Mountain), The Outlaws (Hurry Sundown), Charlie Daniels (High Lonesome), the Allman Brothers (Eat a Peach) and Jerry Jeff Walker (A Man Must Carry on).

The tapes were the soundtrack to our summer.  They spoke of a way of life. Searching for a Rainbow. Freeborn Man, The Ballad of Billy Bonney, Blue Sky, and Getting By.  That summer forever shaped my life.  Seeing the great wide spaces of America opened up possibilities for me that made me refuse to be contained to anyone else’s life or vision for me, but my own.  In later years, I hitchhiked across the country, rode buses and trains, took time off from school, tried to write novels, and experienced as many adventures as I could find. That summer on the road  laid the groundwork for me to become a paramedic. Nobody could tell me I couldn’t do what I wanted, and the EMS life was the road life, always on the go, each stop a different lesson.  I never felt I had to grow up and stop doing what I loved,

Jerry Jeff Walker who sang to us on summer nights as rolled down the highway, died last week. His songs were as guiding to me as anyone’s.  He was from Austin Texas and was best known for “Mr. BoJangles,” a song about a dancing drifter, but the songs I remember him most for were "LA Freeway," "Derby Day," "One Too Many Mornings," "Railroad Lady," "Rodeo Cowboy (Boarding on the Insane)" and "Getting By.”  Even today when I play his music, I feel ageless.  By that I mean I am both the eighteen year old boy I was then, and the sixty-two year old man I am now.    Here’s "Getting By by Getting By":

Just gettin' by on gettin' bys my stock in trade.  Living it day to day..

https://youtu.be/JjkGlZzZLjY

On the album he sang a Bob Dylan song that had the line:

Down the street the dogs are barkin', And the day is a-gettin' dark

It is one of those lyrics I just sing out of the blue and leave it at that. I sing it when I pause to reflect on life’s slow movement from morning to night.  My kids are used to it.  When I was telling my daughter about Jerry Jeff’s passing and she asked me what songs he sang, I said, you know how I always sing, “Down the street the dogs are barking, the days getting dark?”  She nodded.  “That’s one of them," I said.

“You sing that all the time," she said.

Jerry Jeff sang that line in a way that made it not a lament or regret for life’s passing by, but as an quiet appreciation for being alive.  It recognized the intimacy of quiet moments, as he lays next to the woman he has shared a long time with.

My daughter had four basketball games on Saturday, two with an older team where she is a role player, and they won both and she played really well, holding her own, scoring four points in each game, playing solid defense, and making some great passes.  In the evening, she played with her own age group team and was as dominant as I’ve ever seen her.  She was the top scorer, had some dazzling assists, played stifling defense, and when the games were over, went by herself and thanked both the referees (like I taught her) and said good game to the other team’s coach and players.  Her coach told her after how proud he was of her for the progress she’s made in becoming a true leader.  On Sunday, her town recreational soccer team won the senior division championship in a dominating 1-0 game.  She played goalie the first half and only touched the ball once, booting it halfway down the field to start a counter attack, and then she played forward in the second half in which she had a number of good plays and shots on goal.  It was a sweet victory for them as last year’s season ended with tears in a heart-breaking 2-1 loss to an underdog team in the semi-finals.

She napped most of the afternoon and into the early evening.  She was understandably tired.  I sat next to her on the couch for a while, marveling at how big she had grown, and how in not too many years, like her older sisters, she will leave us and go off on her own.  I was hoping we could play some sports together that afternoon, but she looked so peaceful. Rather than wake her up, I went down to the local baseball field by myself, and set up a batting tee next to my bucket of balls, and drove baseballs deep into the approaching dusk just like I used to when I was young.

Jerry Jeff Walker 1942-2020.

A Man Must Carry On.

Book Sale

 

Johns Hopkins University Press is running a sale on public health books, and my new book is in it! Save 30% on Killing Season and other select books with code HPHB when you purchase before 11/6: http://bit.ly/publichtw

Killing Season will be published April 6, 2021.

AHA Guidelines: Key Takeaways

 

The new American Heart Association Cardiopulmonary Resuscitation and Emergency Cardiovascular Care guidelines were released this morning. While the AHA does a major update every five years, since they went to online updates a few years back, the changes are not as momentous as they once were.

After reading the executive summary, here are the key takeaways that affect EMS.

Adult Basic and ACLS

Good CPR remains the bedrock of resuscitation.

Double sequential defibrillation is permitted but it's usefulness if not considered established.

EMS should first attempt an intravenous access before intraosseous. While IO access has become increasingly popular, its efficacy compared to IV is considered uncertain. IO access should only be attempted if IV attempts fail or are not feasible. For me, not feasible would be in a person with no veins, including jugular.

Epinephrine should be administered as early as possible in cardiac arrest patients with non shockable rhythms.

Epinephrine should be delayed in cardiac arrest patients with shockable rhythms. It is permissible after initial defibrillation attempts have failed.

This is later clarified to mean after the third shock.

CPR should always come first in suspected opioid overdoses found in cardiac arrest.

Ultrasound should not be used prehospitally in termination of life decisions. It is permissible to use prehospital ultrasound to identify possible reversible causes of cardiac arrest as well as ROSC.

Pediatric Basic and Advanced Life Support

Pediatrics with an advanced airway should be ventilated at higher rates than previously done. One breath every 2 to 3 seconds or 20-30 breaths a minute is ideal. Be careful on the volume of each breath.

Pedis should be intubated with cuffed ET tubs where available. No longer are uncuffed tubes recommended.

Neonatal

Healthy newborns should be placed skin to skin on their mothers to improve breastfeeding.

Infants with meconium should be intubated if there is evidence of airway obstruction. Suction only if airway obstruction is present after positive-pressure ventilation.

The umbilical vein is the preferred vascular access for infants. IO access is an alternative if umbilical access is not feasible.

CPR Training

Short booster sessions are recommended over a period of time to keep rescuers sharps

These are the highlights that stood out to me.  Not earthshaking, but still some real change.

Go to 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care  to download the documents. I have always found them to be excellent educational material.

Second Wave

 

I am on my knees, wearing a yellow decontamination gown that has already torn at the right forearm and left wrist. I listen to rhonchi in the lungs of an obese febrile man, who likely aspirated on the brown emesis he threw up on himself. The apartment is dim, and smells heavily of cigarettes and urine. There is no bulb in the overhead light and the shades are pulled. Dust rises up from the thick carpet that has likely never seen a vacuum cleaner. My face mask has fogged up to the point I can barely see the blood pressure gauge record 70 something systolic. The man’s SAT is 88%. The visiting nurse doesn’t know anything about him beyond what she can read on her laptop. It says, he had a COVID test three months ago that was negative, she says. He is in no shape to answer any of my questions, foremost among them, does he hang out with or share an aide with the guy on the 2nd floor who’s in the ICU with COVID pneumonia.

When the ambulance crew arrives there is no room to get the stretcher in. I now have a nonrebreather on the patient, who’s SAT is 87%. I hear a belly sound and quickly move the mask off his face as he throws up brown wet vomit that again runs down his stained shirt.

To get him up, we have to roll him onto a bath blanket and then blanket-carry him out to the hallway where the stretcher is in a low position. It takes four of us to do the carry he is so large. I have to stand on the mattress to get leverage. He vomits again on the way to the hospital. I hold back a sympathy puke. I want to take my face shield off but I feel like I am in COVID mosquito cloud, and if I take any protection off -- no matter how uncomfortable, I am done for.

At the hospital dispatch gives us extra time to decon before we get back on the road again.

Walking out of the ED, I see two new stretchers come in with patients on oxygen and the crews in full decontamination gowns.

If this is the start of the feared second wave, then It’s going to be a long fall into winter..

Fatal Overdoses up 17%

 ata just released from the state Department of Public Health shows overdose deaths through July are up 17% over the same time period last year.  2019 which ended with 1200 fatalities represented the previous high for overdose deaths.  Deaths were up in each of the first seven months over 2019 numbers.

Drug Overdoses Monthly Report, January 2019-August 2020

If the trend continues over 1400 people will die of overdoses in Connecticut in 2020.

In other numbers Fentanyl was involved in 84% of the deaths.  Carfentanil was present in only 2 of the deaths.

The largest increase in deaths was in nonhispanic blacks with the death rate in this group increasing by a deeply troubling 42%.

The question we have to ask ourselves in why?

Decreased services, despair, isolation?

Attention must be paid.

Fatal Overdoses in Connecticut Minorities

Unrecognizable

 I was bruised and battered...I was unrecognizable to myself."

-The Streets of Philadelphia

Bruce Springsteen

On November 3, 2020, let's make America a country we can recognize again.

Vote!

 

 

Help is Always Right

The Hartford Courant this week noticed what most everyone else around here has-- panhandlers are on nearly every corner of big intersections these days. Many carry the standard signs drawn on ripped cardboard “Homeless and Hungry.” Some wear masks, others don’t. Some make eye contact, others look down at their feet. They almost universally say “God Bless,” when you roll down your window and give them a dollar. I suspect that is more panhandler etiquette than religious belief. How many of them have lost their jobs, and their homes due to COVID and the economic downturn? And how many of them are substance users? What are they doing with the money? Buying bread to feed their families or buying liquor or drugs and/or alcohol to fight off withdrawal sickness? The article reports that several towns are asking people not to give panhandlers money for fear it will encourage them and increase the problem. Instead, they advocate donating money to local homeless shelters and other charities that service the homeless population. As panhandling grows, Connecticut towns look for answers I am one of those who gives panhandlers money. I donate to a local harm reduction charity too, but I know how much a smile, a look in the eye and a dollar or two goes for someone down on their luck or even someone in need of four dollars to get their next fix to hold the sickness at bay. A couple of dollars means nothing to me. Even though I have a daughter in college and another headed there, I work two jobs and make enough money that I can sleep at night. Between the floor of my car, the ashtray and the center console, I always have a few bills and a ton of change that I am not doing anything with. And if I have a single wrapped protein bar or an unopened bottle of water, I may hand them one of these, too. I do have certain rules about which panhandlers I donate too. I admit I tend to feel inclined toward heroin users. These people I either know by sight as people I have seen on Park Street or who I judge by their gauntness. You give them a buck or two and they are gone, headed to Park Street to get their medicine. The ones I tend to avoid are the ones who are there everyday, who stay in one post and never seem to leave. You give them food and they say thank you and then they put the food into their backpack or shopping bag. I have given apples to heroin users and they have cored them before the light has changed. For heroin users with no teeth, I give them oranges and they have peeled and munched down on them before they have even remembered to say God bless. The ones who put the food in the shopping bag and don’t eat it right away I am skeptical of. There is an old man with a white beard and a can who is a frequent panhandler at one of the major intersections. I stopped giving money once I realized I never saw him on the rainy days and that he never left his post, nor seemed to eat the food people gave him. I began to suspect he was a professor conducting research on panhandling. I'm probably wrong about that and he may in fact have a chilling life story. Another woman I stopped giving to, is on the same corner from morning to night, and every time I drive by she is putting the food someone has given her into a shopping bag. I don’t know if she is putting the food away to save for her family or to hide from people’s view who may be less inclined to give if they see her haul. Maybe she has kids at home, but I don’t think so. I wish I did know her story, and writing about her now makes me feel like a bad person for judging her. If I had to make up a story for her, i would say she has an abusive boyfriend/pimp who puts her on the street not for sex, but to collect change which she has to give to him at night in place of a mattress to sleep on. No easy life that. When I do give to her, I don’t see relief or happiness on her face, just pain. One day I ought to get out and give her ten dollars in return for hearing her story of how she came to be on that corner every day. Sometimes I give heroin users five dollars and ask them to tell me about their lives. I consider it fair value as what I learn is more than I might learn from renting a movie. I think I favor giving my change to heroin users because I know how happy or relieved the money makes them feel, knowing that they can stop worrying if even for a few moments about how they are going to get their next fix. They remind me of the myth of Sisyphus, where Sisyphus is condemned to forever push a rock up a hill and when he gets to the top, it rolls back down and he has to roll it back up the hill. I feel if I give them a dollar or two, it's like I am offering them a chair to sit in and a glass of lemonade to sip for a moment before they resume their relentless struggle. I know some say I am enabling them. I don’t think that my dollar is the difference between their decision to quit using or continue. Addiction doesn’t work like that. I think my human interaction is more important. I’d like to think that it tells them that the world is not all against them, people do not look down on them, but view them as fellow journeyers on this planet, and that kindness still exists in a world that has treated them roughly. Some of my fellow EMS workers will give to panhandlers, but only food. Food is appreciated, surely. But I bought a large pizza once for a group of users once and bought turkey dinner another time to others. While the gestures were appreciated, the food did not fare well for their stomachs that were not conditioned to that type of greasy food in such quantities. I always remember the time I asked one user who was standing in front of the Spanish Market if she wanted two dollars or for me to buy her anything she wanted for lunch. “Two dollars,” she said without hesitation. I gave her the two dollars, then went inside and in addition to my order of roast pork, yucca, rice and tostones, I asked for an alcapurria (made of plantain) and a champagne cola for my friend. Two dollars has more value in a homeless heroin user’s world than food. The two dollars ends the body aching, the nausea, the stomach upset. It brings peace, forgetting, even if only temporary of their painful trail and current place. And I have to tell you. If I can bring them a little bit of happiness, it makes me feel good too. So there is some selfishness there. I feel like Bill Gates. Let’s give some money away. I drive around the city and in twenty minutes I am ten dollars lighter, but I have made five people happy and I feel good myself. Everyone may have their vices. Giving spare change to others is better than me spending it at the bar myself. I go home at night to my warm house, kiss my kds, fill my belly with food and sleep soundly next to my wife. Here’s what the Pope has to say about giving money to panhandlers: Interviewer: Many people wonder if it is right to give alms to people who ask for help on the street; what would you reply? Pope Francis: “There are many arguments to justify oneself when you do not give alms. ‘But what, I give money and then he spends it on a glass of wine?’ If a glass of wine is the only happiness he has in life, that is fine. …Help is always right. Certainly, it is not a good thing just to throw a few coins at the poor. The gesture is important, helping those who ask, looking them in the eyes and touching their hands.” Help is always right. And it turns out it is good for me too. Proverbs 11:24-25 “A generous person will prosper; whoever refreshes others will be refreshed.” The Psalms (112.5), “Good will come to those who are generous and lend freely, who conduct their affairs with justice.” . I feel the same about politics and government. I may be one of the few, but I am always willing to pay higher taxes if the money is going to help others. I don’t like it when government cuts taxes for the right and the programs for the poor are slashed, jobs cut and average American thrown out on the street, while the rich get richer. The term panhandling by the way is believed to come from people holding out tin pans asking for money or alternatively, they are asking for money to buy bread, which is also known as pan. Breaking bread with someone else is a Christian term, meaning to have a meal together, to share common humanity. Help is always right. God Bless.

A Bad Place

 I have a bad feeling about the direction COVID is heading in Connecticut.  Each day the number of cases and the infection rate seem to be rising, but the Governor keeps saying a rise is expected, worth watching but not a real concern yet.  He went ahead with the restaurant's expanded capacity, but as the numbers grow -- not just what I read in the paper, but what I am seeing on the street and at the hospital, it is clear the COVID is BACK.

Daily coronavirus updates: Connecticut reports highest positivity rate since June; hospitalizations also increase

At the hospital, I send notifications to EMS services every time they bring in a COVID patient so they can monitor their employees' exposures and make certain they are wearing the proper gear.  After doing only one case in the entire month of August and only three in September, I have done 10 in the last three days.  No sooner did I a send an email to one service than two more cases popped up on the board.

The cases are in the community, in nursing homes again, as well as elderly housing, assisted living and correction facilities.  

Connecticut has had several outbreaks in local nursing homes including a local home with 24 resident cases and 16 staff members.  It happened last Spring, it looks like it is happening again.

A COVID-19 outbreak at neighboring assisted living facilities in Avon has left one dead and upwards of 50 infected

Connecticut just added three more states to its quarantine list, but at the rate it is going, Connecticut is going to be on its own list.  Yesterday the ten day rolling average was 9 new cases a day per 100,000 residents.  10 new cases a day is the marker for getting on the list.

The USA map looks scary as well. Lots of red and orange, not much yellow.  The news makes me fear the worst.  Politicians holding rallies without masks

And the one voice of reason--the one man we can trust-- Anthony Fauci says,  “We’re in a bad place."

Not good.

Dr. Fauci: ‘We’re in a bad place’ with coronavirus on the rise again

 

Race-Based Medicine

 Most of my EMS career, I have worked in areas that are predominately black.  If I wanted to get a head start on my run forms, I could check heart disease, hypertension, high cholesterol and diabetes for medical history and be right a large portion of the time.  I have always thought that black people were biologically predisposed to these terrible diseases.  However, I have learned that I was wrong.  Black people are at a higher risk for these diseases not based on genes, but based on social factors.  Poverty, poor nutrition, lack of access to health care, employment and opportunity discrimination all contribute to a black person's risk for getting the diseases, in the same way they would contribute to a white person's chances of getting the diseases if they faced similar obstacles.

Check out this talk by Dorothy Roberts, University of Pennsylvania civil rights sociologist, and law professor.

Today, blacks are dying of COVID at higher rates than white, not because of their genes, but because of social factors.

We need to fix this.

 

Opioid Podcast

 I was interviewed recently for a podcast talking about Connecticut's SWORD opioid overdose reporting program.  Check it out here:

 

 

Mass Incarceration

 

When I started as a paramedic over twenty-five years ago, I had a number of set views.  Here are two.

1. People who use heroin have character flaws and are criminals. They deserved their fate. 
2. People who go to jail or have been in jail went because they had character flaws and were criminals. They deserved their fate.

In time, I learned that addiction was not a character flaw, but a chronic relapsing brain disease and that many people became addicted through no fault of their own, but because of system that allowed pharmaceutical companies to prey on people leading to mass prescription of addictive pain pills not in the interest of patient care, but profit.  Users were sons and daughters, fathers and mothers, friends and neighbors, people who should be treated with love and compassion.

Working in the north end of Hartford, I have encountered people with substance use disorder and many people who either been in jail or are no doubt headed there. 

I am sixty-two years old now, and while I am not ready to embrace murders and rapists, I sense there are many people who are in jail or who have been incarcerated who got a raw deal, not just on their conviction, but from life, from the system.  They, too, are sons and daughters, fathers and mothers, friends and neighbors, people who should be treated with love and compassion.

I have mentioned that I am taking a course called anti-black racism, and yesterday I had to listen to an NPR podcast on Mass Incarceration.

Mass Incarceration

Listening to it, I feel like I have been hit in the head with a sledgehammer, trying to knock sense into me.  Of course there is something wrong when America has 2.3 million of its citizens behind bars.  More than 24% of all the prisoners in the world are locked up in our country.  It can’t be that we just have more criminals.

One third of the prisoners are black men.  One out of three black male children can be expected to be sentenced to jail in their lives versus one out of 17 white boys. 

That’s just not right.

I’m not learned enough in the subject to take a deep dive into the issue, other than to say, we need change.

In the podcast, I was stunned to learn that after slavery, many towns, counties and states enacted crazy laws such as, you can’t walk along the railroads tracks, you can’t sell your farm crops after sunset and a black person can’t talk loudly in the presence of a white woman.  Black people were arrested on a mass scale, conceited and sent right back out into the fields to work for the man.  In later years, increasing the number of prosecutors seemed to have led to a corresponding increase in the number of people going to prison.  Becoming a prosecutor also seemed to become a popular avenue to political office and tough on crime prosecution was the way for people to get ahead.  Listen to the podcast.

As a paramedic serving a predominately black community, I feel it is my obligation to understand this issue and the lives of many of the people  I care for and serve.  I will have more to say about this as I learn more, but for now, I’m going to let Sam Cooke bring it on home.

https://www.youtube.com/watch?v=wEBlaMOmKV4

 

Colonel Tye, Mum Bett and Each of Us

In my Anti-Black racism course I an taking at UCONN, I learned about two famous Americans who I had never heard of before.  Colonel Tye and Elizabeth Freeman, also known as Mum Bett.  They both lived during the American Revolutionary War.

Colonel Tye was a New Jersey slave known as Titus.  He was owned by a Quaker, who refused to follow other Quakers in educating their slaves and releasing them on their 21th birthdays. Tye  joined the British side in return for his freedom and gold guineas.  He led many daring guerrilla raids against the Americans, until he died of lockjaw from a musket ball wound to his wrist.  He was such a successful and feared leader that many American patriots claimed that the war against the British would have been won years earlier had the Americans only enlisted Colonel Tye on their side.

When I was reading about him, I had to pause a moment and think, wait, he’s killing Americans.  But then I thought, well, if I were enslaved by people who claimed to be fighting for their rights, and claimed to believe in the rights of everyone to life, liberty and the pursuit of happiness, and I was given freedom in exchange for battling my captors, (and some added gold) -- a man deserves to be paid for his labor), why wouldn’t I?  What is more important?  Love of freedom or love for a country that enslaves you and denies you freedom?  I can’t fault the man.  It wasn’t like he had the ability that all of us do today, to shape and change our country through citizen participation.

Elizabeth Freeman or Mum Brett was a Massachusetts slave who tried to prevent her mistress from hitting her sister with a heated shovel, and instead received the blow herself.  She angrily left her home and found a lawyer to sue for her freedom on the basis that the Massachusetts charter said that all men were created equal.  She won the case under Massachusetts law and was granted her freedom and her master had to pay her thirty shillings, along with the court costs.  Her former slave owner wanted to hire her back as a housekeeper, but she refused and went to work for her lawyer.  Slavery was soon abolished in Massachusetts.  

Any time, any time while I was a slave, if one minute's freedom had been offered to me, and I had been told I must die at the end of that minute, I would have taken it—just to stand one minute on God's airth [sic] a free woman— I would. - Elizabeth Freeman

Colonel Tye and Elizabeth Freeman, names worth knowing to understand our history.

Slavery has been called America’s original sin.  Perhaps trying to abolish it at the founding of the country would have prevented the country from forming its union due to the deep divisiveness on the issue, but like other evil things, the price came due, most notably in the bloody Civil War.  As we approach the 250th anniversary of the Declaration of Independence in 2026, it would be nice to be able to say that the sin and its lasting effects have been wiped out, and while much progress has been made, I don’t see how I can object when someone points out that we are still a long way from true equality in this country.

George Floyd is another name that should be known by all in the the history of this country, although I know George Floyd's mother would rather have him still in the living world alive with her than have his mural on a wall, and his name shouted in synch with the thrust of clenched fists.

And so many other mothers and fathers have no aspirations for their children to be famous; they only wish them safe passage home.

I will always stand for the Star Spangled Banner and the American Flag, but if someone were to kneel next to me, to bring attention to racial inequality, I would put my hand on their shoulder in solidarity.

Colonel Titus and Elizabeth Freeman played roles in where we are today as a county, as each of us play roles in where we will be in the future.

On Tuesday, November 3, 2020, Vote. 

Tap Tap Tap

 

Years ago, I did all of my writing at a desk in a lonely room. I would write on yellow legal pads and then when I had something, I would type it out on my portable smith corona. When my daughter was little, I showed her my old typewriter and she was fascinated with it. She had never seen anything like it. I told her about white out, which for those of you who don’t know was like white paint you put over your mistakes so you could retype over the error without having to retype the whole page. I hitchhiked across the country carrying a backpack, a sleeping bag and my portable typewriter. I went everywhere with it, but when I used it, I only used it at a desk.

Over forty years later, I do most of my writing on a $125 Google chromebook that sits on my lap -- whether I am in the front seat of an ambulance or now, sitting in a gym (mask on) watching my daughter’s AAU basketball tryouts. Her coach called the other night and was talking with me about her playing up another level with older girls, and we discussed the pros and cons -- whether she plays with her own age girls where she can be the star or with other girls where she may struggle. I talked with my daughter about it on the ride over here tonight and she said, Dad, it doesn't matter which team I play for, I get to play basketball!

With COVID numbers creeping steadily up, we don’t know if there will even be a basketball season, but it sure would be great to be able to keep watching her and other girls out on the court running and shooting The ball swishing through the net. Seeing them all smiling. It’s basketball!

The town opened the pool up so I have been swimming four times a week. I am not in the shape I was pre-COVID, but I am slowly getting back in shape. Today I did several 50 yard freestyle sprints. I got plenty of rest in between efforts drinking Gatorade while I caught my breath. It felt great to push myself again, head down, arms reaching fast and long, kicking tight and strong, driving for the wall. Swimming! Racing!

When I work the ambulance, the shift is long, but I try to clear the hospital quickly when it is busy. I am in the rapid response fly car. When the fire radio goes off, I hit my lights and sirens on and notify dispatch where I’m headed. (In our system Fire gets the call first, then they notify the ambulance.) The fire radio gives me a jump on the calls, and I often am the first to arrive on scene. Up the stairs, through the door, down the hall into the bedroom, where a person lies unconscious on the floor, everyone else in the room now looking at me. When I punch out at the end of ten hours, I am tired but fulfilled. I earned my pay and felt my work was valued.

My days are full between work at the hospital and on the ambulance, with taking my daughter to her sports, doing chores around the house (not enough chores as my house is always in a state of disrepair), trying to keep up with the events of the world and trying to make sense of it all with the words I write.

Sitting here pounding away at the keyboard, I feel that life is good. I am making use of time. Every night when I go to bed, I am sad that I have to go to sleep and say goodbye to another day on earth.

I don’t sleep as well as I wish I did. Too much on my mind. COVID-19, Race Relations, Opioid overdoses, the presidential campaign, division and violence in the world. And on a more personal level: Am I being a good father to my daughters? A good husband to my wife? Was I a good person to others? When will I see my father who lives in Florida again? How is my health? (My shoulder hurts, I have a nodule on my thyroid, I cough chronically, I am due for a colonoscopy, but don’t want to go). What repairs do I need to do to my house? (One gutter is falling down. I will soon be in need of a new roof, the back steps are starting to rot, all the rooms need repainting). Have I saved enough to retire when my body can no longer carry me through my working day?

I am still tired when I get up in the darkness of morning as my world spins farther from the sun on its annual trek. But I don’t linger in bed. I don’t tarry. So much to do. So much life to live. I may slip up, and I have no white-out to fix my mistakes, but I keep on typing. Keep on keeping on.

Now I look up and see the ball swish through the net. Joy on my daughter’s face, and then determination and she hustles to get back on defense. No rest on the court. Playing basketball!

Stay safe all. Keep on keeping on!

Tap Tap Tap.

Not All Masks Are Good

 Our hospital has banned bandanas, gaiters and masks with exhalation valves from their universal masking requirements.    This includes all visitors to the hospital, who will be given a surgical mask on entry if their mask does not meet the new requirements.  Additionally staff can only wear homemade masks if they are covering surgical masks.

I know the biggest debate in the country today is about wearing a mask or not.  Science says yes.  Non-believers say no.  But maybe in those areas where universal masks are common and science is dutifully followed, we should be recentering the debate on the quality of the masks if we really want to protect people and hold COVID at bay.

The COVID ACT NOW map shows Connecticut, Massachusetts, New York and New Jersey -the states hardest hit in the early days of COVID -- have all gone from YELLOW to ORANGE in recent days. Even New Hampshire and Vermont who have at times been Green, are now Orange.  (Orange means at risk of outbreak.  Yellow is slow disease growth.  Red is active or imminent outbreak.)

COVID ACT NOW

While we are not RED like many states in No Mask territory, the trend of increasing COVID cases is unmistakable.  We must do all we can.

 

One chart shows the best and worst face masks for coronavirus protection — and which situations they're suited for

 

Empathy, Kindness, Compassion

 

My old boss, former United States Senator and later Governor of Connecticut, Lowell Weicker used to say, the mark of a great country is not how it treats its richest citizens, but how it treats its most vulnerable.  Yesterday, we witnessed President Donald Trump emerge from Walter Reed Hospital, chopper on Marine One back to the White House, stride across the lawn, mount some stairs, stand on a balcony like an emperor and then rip off his face mask and smile (smirk depending on your view).  The same man earlier tweeted “Don’t Be afraid of COVID.  Don’t let it dominate your life.”  He later declared that COVID was less of a threat to people than the simple flu. (COVID has already killed more Americans than the last five flu seasons combined.)

In a matter of days, he had gone from a man with a high fever, needing oxygen to again assume the throne of the most powerful man in the world.  While in the hospital, he had received world class care, including two drugs typically reserved for the sickest COVID patents and an experimental monoclonal antibody “cocktail” not yet approved by the FDA and unavailable to nearly everyone else.   

Some have speculated he never had COVID and this was a political stunt.  I don’t believe that, given the ridicule he has faced oer being infected as well as the high number of people who were apparently infected at the rose garden “superspreader event.”  Others are not so sure he is recovered.  We know  from experience that it is in the later stages 7-14 days post infection often after the person has started to feel better that COVID sinks its teeth in and hauls down its prey.

Let’s hope that’s not the case here.

I write this because a nation is not its leader, it is its people.  Hear the drumming.  210,000 dead and counting.  Nationwide we mourn those we have lost.  Millions more still sick with long roads ahead and for some no recovery from permanent damage.  But don't let it dominate your life.  Today Anthony Faucci warns we could lose another 200,000 this winter if we are not careful.

Trump could face a relapse, experts warn, as president downplays coronavirus threat despite massive death toll  

As we in EMS have learned over the years to look through the eyes of our patients, so should we as a nation look through the eyes of our citizens.  

Empathy, Compassion, Kindness, these are the traits of which we, as a nation, should strive for and be most proud.

Stay safe out there.

Back to School

 Enrolled in Anti-Black Racism -- a college course at UConn.  As an employee at the UConn Health Center, the one credit class is free to me.  It is all online.

The first assignment was watching this video.

Here are the lyrics:

You should've been downtown (word)
The people are risin' (for real?) 
We thought it was a lockdown (what?) 
They opened up fire (damn) 
Them bullets was flyin' (ooh) 
Who said it was a lockdown? Goddamn lie
Oh my, time heals all but you outta time now (now) 
Judge gotta watch us from the clock tower (true) 
Lil' tear gas cleared the whole place out 
I'l be back with the hazmat for the next round 
We was tryin' to protest, then the fires broke out 
Look out for the secret agents, they be planted in the crowd 
Said, "It's civil unrest," but you sleep so sound 
Like you don't hear the screams when we catchin' beatdowns 
Stayin' quiet when they killin' niggas, but you speak loud 
When we ride, got opinions comin' from a place of privilege 
Sicker than the COVID, how they did him on the ground 
Speakin' of the COVID, is it still goin' around?
 
Oh, won't you tell me 'bout the lootin' what's that really all about?
'Cause they throw away black lives like paper towels
Plus unemployment rate, what, forty million now?
Killed a man in broad day, might never see a trial
We just wanna break chains like slaves in the South
Started in the North End but we in the downtown
Riot cops try to block, now we gotta show down, down (City of Los Angeles)
(I hereby declare this to be an unlawful assembly)
(And in the name of the people of the State of California)

Wow.  College wasn't like this forty years ago, but I have to say, there is as much in this song as in many novels.  The lyrics resonate more to me than Edmund Spencer's "Faire Queene" did when I had to read that in English Literature back at the University of Virginia in 1977.

"Sicker than the COVID, how they did him on the ground."

At the beginning of the class I had to say why I enrolled.  I said equality is the great issue of our time.  I want to be convincing when I talk to people.

The first module also includes listening this playlist of 10 songs, including ones by Nina Simone, Stevie Wonder and 2Pac Sakur.

One of the instructors says this is a black centered course and how when she was a child in school, none of the material she was given in her coursework seemed to be about her or the lives she knew.  This course is designed by black people to be about them.  As a white person taking it, my hope is to have the privilege to see life through their eyes, and see where that journey takes me.

I'll keep your informed how it goes and will share what I learn.

Studying hard.

End of October

 

I just finished reading The End of October: a Novel  by Lawrence Wright.  This book had incredible timing as it is a thriller about a pandemic that hit the bookstores in April just as COVID was becoming a household world and fear.  The virus in this book is COVID on steroids and the story is apocalyptic to the 9^th degree.  Still, it was an interesting journey with many moments that seemed similar to today’s events.  The biggest one for me was the desire to blame a disaster that arises out of nature on another country, and instead of working together globally to protect all humankind, countries fight each other, and the results are predictable.

Wayne Cabral

 Wayne Cabral died a couple days ago after a brief illness.  Wayne stopped working for us a number of years ago when he went to work as a paramedic for one of the area towns.  I worked with a few times when he was an EMT over twenty years ago before he became a paramedic himself.  He was respected by us all.  Also a super nice guy.  I never saw him without a smile, even when he was down.  He'd flash that smile and it made you feel the world was a good place.  Even though he didn't work for us, I still saw him often at the hospitals when he was bringing his patients in.  I saw him just a couple weeks ago.  He was the kind of guy you didn't just say hi and nod to, you wanted to stop and really say hi, good to see you, man.

A Go Fund Me Page has been set up for his family.  

Memorial Fund for Wayne Cabral

I'm sixty-two myself now, at the age when I am starting to see ghosts, and instead of being alarmed, I am reassured by their sight.  I know I will see Wayne again.  You work the streets as long as he did, and you become a part of them forever.

EMS Petri Dish

 

Peter Nicholas, a writer for The Atlantic, who covers the White House, wrote an article on August 27, 2020, called "White House, Petri Dish."  In the article, he referred to the White House's West Wing where the President and his top advisor's have their offices as "a corona virus breeding ground."

White House, Petri Dish

The article is getting a great deal of attention now that the President and many of his advisors as well as other staff and leaders have tested positive for corona.   He described the west wing of the White House as a poorly ventilated cluster of small offices where many staff members gather in close groups, without masks.  In his article only the maintenance people wore face protection.  While certain staff members were evidently tested on a regular basis, many others and visitors such as himself were not and could easily introduce the virus to an area where it could be easily spread.

It raises the question for us in EMS to consider.  Are we a model of infection precaution and prevention or are we a petri dish for infection?  Now, I know we all wear our surgical masks when dealing with patents, and sometimes, face shields and full gowns when we suspect the patient has COVID, but are we wearing our face masks at our home bases, where we mingle with others crews and supervisors, in the hospital EMS rooms, and even in the front seat of our ambulance cabs when we sit shoulder to shoulder for the same partner for a twelve hour shift, or in some cases, a different partner for each of the shifts we work?

Many of us at times in our careers, usually earlier on, have felt invincible.  We won’t get in car accidents.  We won’t have  heart attacks, strokes or get lung disease even though many smoke after each call and eat fast food throughout the day.  Many believe they won’t be on the other side of the stretcher.

And I am sure many feel they won’t get COVID either.  Nor will they pass it on.

But given the large amount of asymptomatic transmission can we really be sure we are not passing it on to our partners, patients and families?

The other day, I saw a medic fully garbed with gown, shield mask and gloves.  He placed his stethoscope against the chest of the patient struggling for breath.

In 2009 study found that ⅓ of the stethoscopes of EMS providers contained MRSA methicillin-resistant Staphylococcus aureus (MRSA) bacteria.  Did this medic clean his stethoscope after treating this patient?  How many of us are cleaning our stethoscopes after every use?  How many of those scopes contain COVID?

Third of EMS Stethoscopes Carry MRSA Virus

I don’t mean to sound alarmist, but many Americans who don’t wear masks may feel they are invisible as the White House apparently seemed to feel.  I just don’t want us in EMS to fall into the same trap, particularly as cases seem to be ramping up again across the country.

COVID is the Enemy

In the next to last draft of my new book, Killing Season: A Paramedic’s Dispatches from the Front Lines of the Opioid Epidemic, I quoted a former user, as saying “heroin withdrawal is so painful, it hurts to even blink.”  She further said, “Withdrawal is so bad, I wouldn’t even wish it on Donald Trump.”  She clearly was not a supporter of the President or his policies on addiction.  Understandably.

The publisher’s copy editor, suggested I remove the Trump part of the quote, as it might needlessly alienate some, without adding anything to the strength of the story.  He had a good point.   I deleted the quote.

There is an old saying that you don’t talk politics or religion at work (or with friends).  I try to avoid politics, but it is hard in these times to not speak up or let it be known where you stand on the issues of our time.

All that aside, I do not wish any ill harm on Donald Trump.  Having seen the look of fear in too many patients with COVID who could not breathe, I could not wish it on anyone.  COVID is the enemy. I want only for all us, in this country and in the world, to join together to battle this plague, armed with the best science available and goodness in our hearts. 

Please wear your masks, be sensible in the risks you take, and wish health for all. 

Flu Shot Season

It’s that time of year, I get to practice as a nurse.  I got my R.N. a number of years ago, but I only actually touch patients as a nurse at flu shot season.  While going to nursing school, I got my EMS clinical coordinator job, and that combined with still working full time as a paramedic pretty much killed any time to do nurse work.  The R.N. after my name definitely helps with giving me more credibility working in a hospital where nurses play a powerful role in administering the place.  I went to nursing school in the first place to have a fallback if I got hurt or if overtime dried up.  I imagined working full time as a medic, and part time as an ED nurse.  I will likely go to my grave as never having had to put a foley in anyone.  Every year I get to give flu shots to my fellow paramedics and EMTs.  Not that giving a flu shot involves anything a paramedic doesn’t already know, but in this state paramedics can’t give them.  Has to be an R.N., which is me.

If you haven’t gotten your flu shot yet, you should consider getting it.  They are not fool proof, but have been proven to both reduce your risk of getting the flu by 40-60% or may lead to a milder case should you get it.

  

Methampetamine

 

There is not a lot of methamphetamine use in Connecticut.  I rarely encounter patients high on meth as a paramedic.  I understand there is a fair amount of meth use in certain subcultures in the state, but in general those subcultures rarely generate 911 calls.  We are a huge opioid fentanyl state.

That may change.  I attended a seminar on meth use today (METHAMPHETAMINES 101 FOR PUBLIC HEALTH taught by Justin Alves of the Boston Medical Center, sponsored by the New England High Intensity Drug Trafficking Area) that was very informative.

The word is that meth is coming.  While fentanyl has been moving westward, meth evidently is moving eastward.  Here are some of my notes from the presentation:

Stimulant deaths are on the rise, but they are often linked with opioid use.

Polysubstance use with methamphetamine is the norm.    It is often used with alcohol and amyl nitrate.

Stimulants are used by about 2% of the population, but by up to 6% in the sexual minority community (Note: this is the first time I have heard the term sexual minority.)

Here’s the definition of sexual minority from Wikipedia:  “A sexual minority is a group whose sexual identity, orientation or practices differ from the majority of the surrounding society. Primarily used to refer to LGB or non-heterosexual individuals, it can also refer to transgender, non-binary (including third gender) or intersex individuals.”

40% of all overdose deaths in America involved stimulants.

75% of all drug arrests involved stimulants.

Amphetamine related hospital costs exceeded $2.17 billion in 2015.

Efforts to stop people from cooking their own meth led to drug groups filling the void with much higher purity meth.

Meth intoxication includes Mania, Deranged Thinking, Hypersexuality, and Hyper-focus.

Overdose includes Hyperthermia, Tachycardia, Psychosis, Rhabdomyolysis and Choreiform Movements

According to wiki, Choreiform movements are “repetitive and rapid, jerky, involuntary movement that appears to be well-coordinated; often seen in Huntington's disease.”

Meth withdrawal is much more drawn out than opioid wihdrawl often taking weeks or months.

There is no naloxone to reverse meth overdose and there is no methadone or suboxone to help get people off of it.

Treatment for meth OD includes keeping the patient safe, regulating sleep, and treating psychotic symptoms.

Try to deescalate, speaking calmly and keeping a safe distance.

Like all victims of addiction, meth users should be treated with compassion and kindness, offered direction to rehab or local harm reduction agencies.  While there are many paths to meth addiction, a disproportionate number of users are victims of childhood trauma.

For acute episodes, the treatment is benzos, preferably Versed or Ativan with Haldol being second line, and Ketamine only when other drugs fail.

The only patient I had on meth this year was visiting from New York State.  He had lost his traveling friends and called 911 himself from a downtown street.  His heart rate was racing in the 160’s, he was shaking, agitated and scared.  I gave him IV Ativan and it calmed him down considerably.

I recall another patient on meth a few years before who was also from out of state, heart rate in the 190’s, talking 100 miles an hour and I felt he as was on the precipice of violence, his movements and anger was so sudden and jerky.  Some coworkers in his temporary construction crew had called 911 on him after seeing him shoot up.  Ativan barely touched him.

As far as stimulants in Connecticut cocaine is huge and we get lots of cocaine/opioid calls, but from what was explained in the seminar, meth is to cocaine what fentanyl is to heroin.  Much stronger and way more dangerous.

Not looking forward to its arrival,