COVID Trends

 

I have been following the COVID trend since the epidemic began.  To me, the best indicator of COVID in our area has been the hospitalizations.  Cases numbers can change based on the number of tests and who is being tested, the same with positivity percent.  Deaths, can be a good indicator, but they lag the onset of serious COVID cases by several weeks,  Hospitalizations, provided they haven’t changed the criteria for who is admitted to the hospital with COVID should be a reliable indicator of not just who is getting sick, but of the severity of the epidemic.    

Back in March and April, COVID cases at our hospital shot up precipitously as the disease burned like wildfire through our area nursing homes, reaching its zenith the last week of April, and then by the end of May fell fairly precipitously.  In those early days, nearly all the hospitalizations were people from nursing homes, elderly from assisted living, people in prisons, and group homes.  The first spike lasted until June, and then nearly disappeared entirely by the end of July.  We were struck by the second wave the first week of October, saw a slight lull in early November, then rocketed back up reaching a peak in early December.  This time, the cases while still containing elements from the first wave, had many more elderly in the community as well as those with comorbidities like obesity, hypertension and kidney disease.  While the second COVID spike was not as high as the first, it lasted much longer from December to the start of February in a slowly declining plateau.  It has since declined significantly, but now appears to be be plateauing again.  The other day I noticed of the ten patients we had left in the hospital, down over 80% from our December high, not a single one was over the age of 60.  COVID has virtually disappeared from our SNFs.  The experts say that is due to the vaccinations.

I read yesterday in the New York Times that cases nationwide and worldwide have stopped their decline.  While they attribute the recent decline to vaccines, the worry is that the variants may now be coming into play, combined perhaps with pandemic fatigue causing people to be a little less cautious.

The Coronavirus Is Plotting a Comeback. Here’s Our Chance to Stop It for Good.

We are at an inflection point.  Which direction will the graph go in next?  I am hoping here in Connecticut, where he have been hailed as being one of the best states in vaccine distribution, the graph will soon look like it did this summer with few cases, and our spirits will lift with the warm weather of Spring, and that similar patterns will show all over the globe.  I just checked our census and we are the lowest now we have been since October.  I remain optimistic, but cautious.

Keep wearing your PPE.

Dead

 As I approach the house with my medic pack over my shoulder and my monitor and isolation bag in my hands, two boys, maybe fifteen or sixteen, stand on the sidewalk out front of the building, and look at me expectantly.  “He’s not alive?  Is he?  Is he still alive?” the shorter one asks.

I keep walking, up the stairs and through the front door, headed for the third floor.  The fire department is there waiting for me.  They let me through.  The apartment, empty of furniture, looks under haphazard renovation.

The man, maybe in his sixties, dressed in a blue winter jacket and a red knit hat, is on the floor.  He has rigor mortis with lividity.  His limbs are stiff and his blood has pooled to the dependent parts.  With the freezing temperatures outside and no heat in the apartment it is hard to tell how long he has been dead. The boys outside apparently found him while they were doing whatever it is kids do when they trespass. The building owner says the man is homeless.  He last saw him a week ago down on the corner by the ranch house restaurant. He was sick.   How did he die in this cruel winter? I don't know. Opioids?  COVID? Hypothermia?  No matter the way, he died alone.  I run my six second strip of asystole, and write down the time.  I hand the arriving police officer the presumption of death information, and exit.

The two boys are still outside.  “Did he have a pulse?”  the shorter one asks again.

I shake my head as I walk past.

 

Drug Use for Grownups

I just finished reading Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, an audacious and provocative book by Dr. Carl Hart, a professor of psychology and a "preeminent expert on the effects of recreational drugs on the human mind,"  in which he describes his recreational drug use, including heroin and methamphetamine.  His argument is that drugs should be regulated just like alcohol and in some states now, marijuana.  In America, he argues, we have the right to pursue life, liberty and happiness, as given us in the Declaration of Independence.  This, he says, should include the right to get responsibly high if it brings us happiness.  I am not saying “Right on!” to this argument but I’ll concede he does make some good points.  The reason people are dying of overdoses today is they are using in the shadows (driven there by law and stigma) and the drug supply in America is lethal due to poor mixing of fentanyl and the unknown additives added by dealers to fill out and or enhance their product.  Legalizing and regulating the supply would ensure that people are using medical grade drugs so they would be less likely to suffer overdose from an unexpectedly strong dose or other side effects from unknown adulterants, and with the recreational use of drugs being legal, they may be less likely to shoot up behind locked doors or behind dumpsters where no one will find them until they are cold and stiff.  Shout this from the rooftops.  True.

I have no doubt that heroin brings the author great happiness.  That’s what the appeal is of heroin for many -- the euphoria.  Lenny Bruce famously said, shooting heroin is like being kissed by God.  However, for some, but not all, it starts them down a path that is difficult to return from.  If you have money, a good job, stable relationships and no underlying mental health problems, you may be able to use heroin without issues, just as many in America are able to drink regularly without major negative issues.  Unfortunately, there are many, some with genetic predispositions to addiction, who’s “recreational” use of heroin might lead to bad endings.

When reading a book like this, it is hard to guess if the author has any doubts or hesitations about what he writes or if like many of the talking heads on TV, he deliberately takes an extreme position and touts it.  People like unambiguous viewpoints and he certainly has his.  If he was less insistent, the book would receive less interest and the discussion it generates would be far less interesting or far less able to move established dogma, which clearly needs some movement.

Reading the book, I imagined coming home from a long shift on the ambulance, putting on some relaxing music, turning the lights down low and snorting a line of two of medical grade heroin, and then just drifting off into a bliss that would make me forget all my worldly hassles and my sixty-two year old body aches and my occasional wondering what life means.  I would just float in the happiness the author says heroin offers, forgetting about the darkness at the periphery of all our worlds.  I wish sometimes I could do that.

I have two Vicodins left from my dental surgery a couple years ago.  Some nights I think about taking one just to chill out and feel better, to escape into bliss.  But the truth is from what I have seen over twenty-five years of responding to opioid overdoses, I am afraid to even take half a 5 mg pill.  I picture myself cold and dead in my bedroom, and another medic, his boots wet with snow and ice, standing over me, calling the time.

***

Here's a story on the book and author:

A Columbia professor who uses heroin says the drug helps him maintain a work-life balance and should be legal for everyone

Pandemics

 

COVID is on the retreat in Connecticut and much of the nation and world.  Whether it is the effect of vaccinating those most at risk, the cumulative effective of masking and social distancing or the virus is just getting tired (hopefully not just resting before a new variant-fueled surge), cases are in rapid decline.  The COVID ACT-Now map, which in January was solid dark red, indicating uncontrolled outbreak, is now more orange than red, and I predict in a day or two Connecticut will also turn from red to yellow, indicating the level has gone from active outbreak to at risk of outbreak.  (Never mind, I just checked it again and it has officially turned orange).

Our hospital is down to less than 10 COVID patients in the hospital and I have gone two days without having to notify EMS of any COVID positives they transported.  When I work the street, I still gown up, but the patients with SATs in the 70s are nowhere to be found. 

Our Governor has announced he is loosening a number of restrictions, with more to follow.  I sure hope this is not just another lull.

But the other pandemic is still raging.  A newly released study published in JAMA  looking at emergency department visits  for opioid overdoses showed a 29% in the period March to October 2020 over the same period in 2019.  Today, I read the latest data from the state public health department and the office of the Connecticut Medical Examiner.  In 2019, 1200 people lost their lives to overdoses in Connecticut.  For 2020, the number stands currently at 1,359 with 78 cases pending review.  That’s an increase of 13% and threatening to go higher.  Early data from January shows 48 deaths in the first two weeks with 170 pending cases beyond then.  Every day, as part of my job, I read the Connecticut SWORD case reports where EMS calls in opioid overdoses to the Connecticut Poison Control Center.  The narratives remain chilling: parents finding their kids dead in their bedrooms; spouses finding their partners dead in the homes they share; strangers finding people dead in parked cars and behind dumpsters.  Hear the drumming.  Another shovel breaks the cold earth.

If COVID has taught us anything, it is that we are all vulnerable.  We may think that people who suffer from the disease of opioid addiction just decided to become addicts, but it couldn’t be farther from the truth.  Whether through a medical prescription for an injury (sports, car accident, fall) or an innocent experimentation, fathers, mothers, sons, daughters, relatives, friends, and neighbors are sent down a path from which many will not return.

We are our brother’s keeper.  It’s time to focus back on the opioid epidemic and consider bold steps (safe injection sites, medical heroin, massive anti-stigma campaigns and harm reduction funding, and most of all love and empathy for all) to end this horrible public health crisis.

 

EMS Safety

 Scene Safety BSI.  (BSI is body substance isolation). That’s what we are taught to say at the start of any practical scenario.  You don’t practice Scene Safety BSI, you fail the station.

Two interesting articles recently on Jems.com about EMS safety.

The first, Safety is Third, Not First, and We All Know It Should Be.  (The authors put safety behind 1. Getting the job done and 2. Having fun.

The second, Safety First or Safety Third: Considering Practitioner Safety in EMS, is a rebuttal.

I find the first article provocative in questioning a fundamental tenet of EMS.  It argues that EMS should be about risk assessment as opposed to absolutes.  I will let you read the articles and decipher their arguments. Some of their difference is just semantics.  They both clearly want EMS responders to be safe.  The authors of the first article think they will be safer if they are not blanketed with the Safety First Motto, which can easily loose its significance.  They prefer you think about it when it matters most.

I like the line in the first article “It depends.”  My boss, the EMS medical director at our hospital, does an entire lecture on “It Depends.”  I agree in EMS, where things often aren’t black and white, “It depends,” is often the best answer.

If safety truly was first at all times, EMS would not exist.  What we do -–drive lights and sirens in vehicles with less safety standards than cattle cars, respond to scenes that can become hostile without warning, deal with patients with infectious disease and others with histories of violence, at all times of day and in all types of weather-- is fundamentally unsafe.  The physical and mental health risks of our occupation are known to all.  Our job requires that someone respond to traumatic events and that someone is us.  We respond despite the known danger.  We can and should do our best to mitigate our risk.  We can accomplish that better with common sense and risk assessment based on the particulars of a scene than with the "scene safety, BSI" slogan.

When I began in EMS, we were the only responders in the city.  The fire department came out if requested for motor vehicle extrication and the police were there if active violence was reported beforehand.  Other than that it just me and my partner.  We gauged the risks of each encounter.  Some scenes we never entered, some we backed out of, but we never routinely sat in the ambulance waiting for someone else to assess the situation unless it was a clear HAZMAT or a report of man with gun.  I remember many years later, I was precepting a new paramedic and when we got sent to a psychiatric call, he wouldn’t get out of the ambulance until the police had arrived.  He said we had to stage.  This was a new term for me.  “Staging” is commonplace today.  We are told to stage on many calls.  This often ends with us waiting on scene for thirty or minutes while the police investigate.  There have been many times I have been on scene, staging a block away, only to find the police came and went.  I know some crews love to take advantage of these notification lapses to get a break.  I have also been told to stage for an overdose, and waited on the scene for fifteen minutes for the police to arrive only for them to scream for a medic.  A person who could have been revived fifteen minutes before, is now in cardiac arrest.

Recently, in “The Door” I discussed the dilemma of immediately putting defib pads on a cardiac arrest victim or waiting to properly attire myself in all my PPE.  

I am not calling for us to all become dead heroes in the name of glory.  I merely saying we should recognize that what we do is inherently unsafe and we should use our best judgement in each individual scenario to make each scene as safe as we can without turning our backs on the job we have chosen.