tag:blogger.com,1999:blog-83825232024-03-13T06:39:34.375-04:00Street Watch: Notes of a ParamedicThis paramedic blog contains notes from my journal. Some of the characters, details, dates and settings have been changed to protect the confidentiality of people and patients involved.Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comBlogger1043125tag:blogger.com,1999:blog-8382523.post-81376590850762579192021-10-31T19:16:00.002-04:002021-10-31T19:24:45.757-04:00Reflections<div class="separator" style="clear: both;"><a href="https://1.bp.blogspot.com/-l6doEjhqUO8/YX8i16C0M4I/AAAAAAAAG_M/rLbwOTezwik522O-RSok7xpVQ1crqxWjACLcBGAsYHQ/s2048/IMG_7103.jpg" style="display: block; padding: 1em 0px; text-align: center;"><img alt="" border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://1.bp.blogspot.com/-l6doEjhqUO8/YX8i16C0M4I/AAAAAAAAG_M/rLbwOTezwik522O-RSok7xpVQ1crqxWjACLcBGAsYHQ/s320/IMG_7103.jpg" /></a></div><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Thirty three years I’ve been in EMS now and if there is one line of advice I have for people starting out in the field, or just for life in general for that matter it is:</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-family: inherit; font-weight: 700;">Don’t Be an Asshole</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">EMS is stressful and we are constantly in situations that may put us in conflict with others. I sit in EMS rooms and listen to people bitch about coworkers, patients, patient’s families, dispatchers, nurses, doctors, police, fire, bystanders, management, the union, their spouses, the government, their sports teams, their health, the weather, etc. Serious negativity.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Sure some of it is blowing off steam, but when everybody does it, expected conversation comes to be about who is having the worst day, who can be more negative about life. You carry that attitude onto a scene and someone gives you a hard time, and it can quickly becomes about standing up for yourself by putting others down. I told that nurse where to go. I gave it right back to that patient’s family. I told that addict to stop using drugs and wasting my time or he’s going to end up dead and good riddance.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I had to pull a young woman aside and talk to her about that.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Can’t we all just get along and show some empathy for our fellow human travelers on this earth. Can we at least replace insults with humor?</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When I had a negative partner, it inevitably turned me negative and I always went home in a bad mood. The best partner I ever had was an older woman at the time who put cheery stickers in the ambulance, and always had nice things to say to everyone and was always to the patients even the grouchy, miserable ones. I loved working with her. She didn’t wear me down. I had another great partner who was always quick with a joke, who knew how to defuse tension, and who made coming to work fun just like two buddies hanging out, marveling at the crazy wonderful and diverse world we find ourselves in. Now, I work in a fly car by myself. It is lonely at times, and if I feel negative, I can only blame myself. And if I am positive, then good for me. Be happy.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I’ve started watching this show on AppleTV called <a href="https://tv.apple.com/us/show/ted-lasso/umc.cmc.vtoh0mn0xn7t3c643xqonfzy" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">Ted Lasso</a>. It’s about a man (a coach) who is optimistic, who believes in giving everyone the benefit of the doubt, who has a big heart, knows that no one is perfect, including himself, and has the emotional intelligence to recognize it is not all about us, but more about what we can do to make others’ lives better.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I want to be like this man. I am trying but not always succeeding. Yesterday I was abrupt with a woman, who screamed at me, her spittle coming close to my face, for not putting oxygen on her family member, who was having an anxiety attack. “He doesn’t need it,” I said. “His oxygen is 100% and his lungs are clear. He’s speaking in full sentences.” “Well, I’m in the medical field, too. You need to do something.” I said nothing more to her, but I could have been more reassuring, my tone less strident. Later, a man leaned out of a second story window and told me I was too slow getting out of my vehicle, not understanding I had to put myself out with dispatch, unfold my long legs to step out of the car, put on a face mask, then open up the back hatch to grab my house pack, my heart monitor and unlash an grab an oxygen tank, and then navigate and uneven cracked stairway up to the building door. “Hey, I shouted to him. “I’m the first one here, cut me a break!” I didn’t need to say that. I should have just left it alone.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">On the positive side, all day long, I let cars cut me off. I waved them in. I looked every first responder in the eyes and focused on them when they gave me their reports. I said thank you to many people. All of my patient handoffs at the hospital were professional with some joviality thrown in. I responded to a woman down, only to find the woman alert and crying sitting on the curb, leaning against a street sign. She did want to go to the hospital and apologized for bothering me. She said she needed detox, but did want to go to the ED because she would have to lie and tell them she was suicidal, which she wasn’t. I gave five dollars and wrote her walking directions out on how to get to the harm reduction center where they could help her. I didn’t blame her that she never made it there. Instead of immediately exciting a house after calling the time on a woman who sat cold, stiff and lifeless in her favorite chair watching TV, I stopped and said a few words to her son. I asked him what he most remembered about his mother and listened as he told me of how she sang to him when he was a child. I didn’t get angry when the dispatcher didn’t acknowledge my requests to go in for my crew change like an old partner of mine used to. She was probably busy with work I could not see. On the third request she answered and sent me in. Dispatcher is a thankless job.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When I finally made it to the base, I gassed my vehicle up, restocked my supplies and turned the car over to my relief. After I punched out, I stopped at the grocery store and bought chocolate for my wife and ice cream for my daughter. When I got home, I did not snap at them when they did not acknowledge my “I’m home!” I showered and sat down with them, and when their show was over, we watched another episode of Ted Lasso, where he makes a surprisingly kind and human gesture to someone expected. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When I come home on Friday’s, my wife knows I can be touchy. The pace of the city and being in the rapid response car is relentless and at my age it tires me out, and when I am tired, I can get a headache and be quite irritable, but I wasn’t last night. I was grateful for my life and family and for work that is rewarding and for those in the world who show the way, how to be good to others and not be an asshole.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">As we watched Ted Lasso, I asked my daughter what she thought of him.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“He’s a good guy,” she said.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“Damn straight, he is!”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Thank you all.</span></p><div class="addtoany_share_save_container addtoany_content addtoany_content_bottom" style="background-color: white; box-sizing: inherit; clear: both; font-family: lato, lato, "helvetica neue", helvetica, arial, sans-serif; font-size: 16px; margin: 16px auto;"><br /></div>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-16132499345237652812021-10-31T19:09:00.002-04:002021-10-31T19:21:16.545-04:00High Dose Naloxone
This week I was asked by the Connecticut Alcohol Drug Policy Treatment SubCommittee to comment on the new FDA approved high dose 8 mg naloxone product, Kloxxado, from the EMS perspective,<div><br /></div><div> Here’s what I told them:</div><div><br /></div><div>Three Points</div><div><br /></div><div>1. High dose naloxone has no place in EMS/First Responder arsenal.</div><div><br /></div><div>2. It has not been proven that higher doses of naloxone are needed to reverse fentanyl overdoses.</div><div><br /></div><div>3. High dose naloxone is more likely to cause precipitated withdrawal than traditional doses.</div><div><br /></div><div>Point 1:</div><div><br /></div><div>We in EMS are taught to assist ventilations and administer naloxone at the lowest dose possible to achieve spontaneous ventilation/oxygenation. The goal is not to fully wake the person up, but simply to restore their ability to ventilate/oxygenate themselves. I typically administer naloxone at 0.1 mg/min when I have an IV or 0.4 -1.2 IM if I don’t. I give 1.2 mg for patients who are blue and apneic. 0.4 if their breathing is agonal. I rarely ever give more than 0.4 IV and rarely need a second dose if I deliver it IM.</div><div><br /></div><div>Our local fire department carries the 4 mg IN and if I am on scene before they have given it, I tell them to hold off, and just bag the patient until I can give a more moderate dose. Too many times I have arrived after they have given it, only to have the patient sit up and vomit towards me.</div><div><br /></div><div>Point 2:</div><div><br /></div><div>The two studies the drug companies seem to use most that show EMS is using more multiple doses than in previous years did not take into account the route (IV, IM or IN), what the doses (.04 or 4 mg) were or time between doses (1 -5 minutes) or who had administered the doses (layperson, PD, Fire, EMS).</div><div><br /></div><div><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026856/">Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing</a> </div><div><br /></div><div><a href="https://pubmed.ncbi.nlm.nih.gov/31361589/">Who receives naloxone from emergency medical services? Characteristics of calls and recent trends</a></div><div><br /></div><div>
Other research has shown despite increasing fentanyl presence, more naloxone has not been needed for reversals.</div><div><br /></div><div><a href="https://pubmed.ncbi.nlm.nih.gov/31471760/">Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl</a></div><div><br /></div><div>
<a href="https://pubmed.ncbi.nlm.nih.gov/34278904/">Fentanyl: a comparison of blood fentanyl concentrations and naloxone dosing after non-fatal overdose</a></div><div><br /></div><div>
<a href="https://pubmed.ncbi.nlm.nih.gov/29558283/">Amount of naloxone used to reverse opioid overdoses outside of medical practice in a city with increasing illicitly manufactured fentanyl in illicit drug supply</a></div><div><br /></div><div>
A word on naloxone dosing:</div><div><br /></div><div>The number of doses does not equal the amount of dose. 4 doses of 0.1 IV is much less than 1 dose of 4 mg IN.</div><div><br /></div><div>It is not uncommon for a bystander to dose, the first responder (police/fire) to arrive and dose, and then EMS (ambulance) to arrive and dose all within a few minutes. Had a paramedic arrived first, the patient likely would have only gotten on 0.4 mg dose and the patience to bag the patient until he began breathing on his own.</div><div><br /></div><div>It is not uncommon for bystanders to empty all their available naloxone into unresponsive people. We regularly receive reports of people getting 16 mg and 20 mg total doses from collected bystanders.</div><div><br /></div><div>It is also not uncommon for people who are “dosed” (depressed consciousness) to receive naloxone when naloxone should be reserved for severe respiratory depression/apnea.</div><div><br /></div><div>Point 3.</div><div><br /></div><div>High Dose naloxone is more likely to cause sudden severe opioid withdrawal, including agitation, restlessness, aggression, body aches and cramps, diarrhea, nausea and vomiting, excessive sweating, and increased blood pressure.</div><div><br /></div><div>In Connecticut, we examined the rate of side effects (nausea, vomiting, agitation) from single dose intranasal naloxone administration for suspected opioid overdose in Hartford, Connecticut for the period of June 1, 2019 to December 31, 2019.</div><div><br /></div><div>Here’s what we found:</div><div><br /></div><div>33.5% of suspected opioid overdose patients suffered adverse effects after receiving a single dose of intranasal naloxone.</div><div><br /></div><div>20.5% of those who received 2 mg IN had side effects. </div><div><br /></div><div>38.1% who received 4 mg IN had side effects.</div><div><br /></div><div>6 patients who received doses of 0.5 mg and 1 mg via the intranasal route suffered no adverse effects.</div><div><br /></div><div><a href="https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/ems/pdf/SWORD/SWORD-newsletters/2021/SWORDfeb2021NL_FINAL.pdf">SWORD February 2021 Newsletter</a> </div><div><br /></div><div>Given the increase in side effects, high dose naloxone may cause hesitancy in people who use opioids to administer the antidote to their friends. I have been on many scenes where people in withdrawal are extremely angry at their friends for having administered naloxone, as they kneel on the ground puking and cursing, and I have seen how this has deeply bothered their friends, and likely caused them to wonder if they did the right thing, if maybe they should have waited or tried more stimulation instead of robbing them of their high and putting them into excruciating withdrawal.</div><div><br /></div><div>I told the committee these are the decisions that need to be weighed:</div><div><br /></div><div>Will increased side effects from high dose Naloxone cause hesitancy to use naloxone in overdose? </div><div>We should listen to People Who Use Drugs.</div><div><br /></div><div>Is there convincing data to show that 8 mg IN will save people that 4 mg IN will not? There is not.</div><div><br /></div><div>Currently we say wait 3 minutes between 4 mg IN doses. If we go with 8 mg, are we saying to those who carry 4 mg that they should give both nasal injectors at once? I don’t think so.</div><div><br /></div><div>Who is pushing the need for higher doses? Pharma versus Harm Reduction. Most harm reductionists I know are against the high dose naloxone, while Big Pharma is pushing for the higher dose products.
A couple of weeks ago, I met with a representative from a well known Pharma company who wanted to hear from me about how to combat the synthetic opioids that require more doses.</div><div><br /></div><div>I told them much of the above, as well as sending them a copy of an excellent opinion piece by Lucas Hill published in the International Journal of Drug Policy</div><div><br /></div><div><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8454200/">Increasingly powerful opioid antagonists are not necessary</a></div>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-91511696681881998692021-10-30T19:24:00.001-04:002021-10-31T19:31:16.861-04:00Kryptonite<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-dPvtRQmzlIs/YX8mrrulIBI/AAAAAAAAG_Y/10tnuMrjntca5xnEY5vh1JP-IpvZes4hgCLcBGAsYHQ/s174/kryptonite.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="174" data-original-width="148" height="174" src="https://1.bp.blogspot.com/-dPvtRQmzlIs/YX8mrrulIBI/AAAAAAAAG_Y/10tnuMrjntca5xnEY5vh1JP-IpvZes4hgCLcBGAsYHQ/s0/kryptonite.jpg" width="148" /></a></div><br /><p></p><p>(An excerpt from a fictional work in progress.)</p><p><i>Prologue</i></p><p><i>Hernando already had a 200-gram bag of heroin on the table, as well as a smaller baggie of fentanyl, a canister of baby formula, four packages of Benadryl, and several small open cardboard boxes, each holding 600 of the blank glassine envelopes they would be putting their product into. Enrique helped Hernando package the heroin to be distributed to the dealers Hernando had below him. In return, Enrique got a break on his own supply.</i></p><p><i>Hernando used to do a 40/60 cut of the heroin with the baby formula, but Enrique had convinced him to do a 50/50. The better the product, the quicker they would sell out, and the faster their brands and reps would grow. There was so much quality on the streets these days, no one wanted to buy shit. Now that Hernando was also getting a few grams of fentanyl to mix in, their brands were banging, although Hernando always urged caution, and resisted all of Enrique’s attempts to move to an even bigger fentanyl presence. Fentanyl’s the future, Enrique told him. He argued that the fiends loved the rush fentanyl added, and the fact that it lasted three to four hours before they started feeling sick again (compared to heroin’s six to eight hours) would only increase sales. But Hernando countered that it was better to be the longest-selling dealer than a flaming star. Kill too many of your customers and not only would your business drop, but the judge would drop the hammer on you. Hard time.</i></p><p><i>They put the heroin in a coffee grinder to break it down into as fine a powder as possible, straining it again in a sieve, and then mixing it with the baby formula and Benadryl. The Benadryl had been Enrique’s idea. It added another pleasing rush, and with all the competition out there, they needed to stand out. He and Hernando made an additional batch that they mixed with brown sugar.</i></p><p><i>Hernando was very accommodating to his customers. There were many who stayed away from white heroin for fear of the fentanyl, which was fifty times stronger than heroin, but was indistinguishable from heroin by sight. Some dealers were starting to not even sell heroin at all. They just threw a healthy sprinkle of fentanyl in with the cut. It got the job done. Many customers, who had overdosed on white heroin or who were scared over the loss of friends who had died from fentanyl-laced heroin, were just focused on maintaining normalcy. For them, ordinary heroin was preferable to recapturing or exceeding that first great high. They had learned to be disappointed, and now they just wanted to be alive and not sick. Others who were afraid of fentanyl made certain they used smaller amounts of a new brand just to be sure of its potency. Many told tales about waking up hours later with a needle still in their arm. Others woke up in an ambulance, their high robbed by Narcan, their extra bags gone. If they had been in a car, their car was towed and impounded, or left in an unsafe area subject to easy vandalism. One by one, they were learning to be cautious. Still too many users were greedy, and did not moderate enough. Whether it was to escape their suffering or to end it, it was the way of the world. That’s fiends, Enrique thought. Really, that’s all of us. Living on the razor edge. Keeping the ambulance people working.</i></p><p><i>To the white batch, they added the fentanyl. Hernando watched Enrique closely to make certain he mixed it evenly, but Enrique was a master of sleight of hand, making certain a section of the pile wasn’t all the way mixed, and that was the dope he would use for his own packing and it would be of a higher potency.</i></p><p><i>“I’m watching you,” Hernando said. “I know you spiked the last batch of your Kryptonite. You’re one heartless motherfucker for being so young.”</i></p><p><i>“No, I think you’re just selling to the same old tired fiends. I’m getting all the new blood that isn’t cynical to the product yet.”</i></p><p><i> “It doesn’t bother you when they take their last breath?”</i></p><p><i>“It’s not that I don’t warn them. My packages don’t say: ‘Love & M&Ms.’ They say: ‘Kryptonite! It knocks down Superman. Even if you’re wearing a cape, you best look out.’”</i></p><p><i> “Only truth is you’re going to pay for it. We all are. Some sooner and that’s going to be you, my cousin.”</i></p><p><i> They used 0.1-gram spoons to parcel the combined product into each of the glassine envelopes. Enrique had a 0.15-gram spoon that he’d bought on Amazon that looked identical to the 0.1-gram spoon that Hernando provided. He would switch spoons out when he was packing his product, but he would be careful not to overfill. He figured he would only add an extra 0.02 to his envelopes. He had added the requisite amount of baby formula to the initial mix so the count would even out. A little extra powder, a little extra potency. People would be saying that he was the Man.</i></p><p><i> “I might as well tell you now: you sold your last bag of Kryptonite,” Hernando said.</i></p><p><i> “What are you talking about?”</i></p><p><i>“Don’t you watch the news, man? They showed your bag in the papers. It’s time to distance.”</i></p><p><i>“I saw that. Kryptonite! It looked good. I’m going to start a scrapbook.”</i></p><p><i>“You’ll be peeking out of jail bars, you keep selling it. “</i></p><p><i>“Risk of the game.”</i></p><p><i>“For a smart boy, you’re stupid. Somebody’s got to look out for you. Mario came by a couple hours ago complaining about you taking his business, making his threats. He’s selling Superman, and you go and antagonize him by coming out with Kryptonite. He’s still mad you came out with Lebron when he was selling Kobe, and your Lebron packs twice the punch.”</i></p><p><i>“Lebron throw down,” Enrique said. “He posterizes any fiend that gives a go.”</i></p><p><i>“I know your rap, but Mario got to be respected. I said I’d talk to you and, as a peace offering, I sold him your stamp for $300.”</i></p><p><i>“$300, that’s my stamp!”</i></p><p><i>“And it’s my $300 for you overmixing the fentanyl. I saw you pull that move again. Don’t think I don’t know you.”</i></p><p><i>“Fuck.”</i></p><p><i>“I’m doing you a favor on account your momma was my favorite tia, and out of respect for your old man, an original bad man, and crazy in the head like you.”</i></p><p><i>“Mario’s gonna sell all cut and call it my Kryptonite. That’ll tarnish my reputation. And how am I going to stamp my bags? My new designs ain’t arrived yet.”</i></p><p><i>“I got you covered.” He tossed a plastic STAPLES bag on the table. A rubber stamp set was inside. “$11.99. Ten stamps. I’ll give you your first choice.”</i></p><p><i>“Are you kidding me? I’m not representing any of those. A+, check mark in a box, light bulb, a ladybug, ‘Great Job.’ Who’s going to buy that except some eighty-year-old school teacher?”</i></p><p><i>“It isn’t the brand, it’s what’s inside, and the brand just reminds them they got it from you. You and your art. It isn’t the art they’re loving, it’s the product. When they’re done, the product is in their blood making all their worries vanish, and your bag—it’s crumpled up and thrown out the car window, lying on the cold ground.”</i></p><p><i>“No, you don’t understand the fiend. The picture of that bag is imprinted on his brain like a picture postcard of a girl in a bikini at the ocean. It’s a pleasure memory. You stick a fiend in one of those MRI machines and the doctors go ‘Oh my goodness! Look at that!’ Amid all the black and white and grey medical image, right there in the middle of the brain in full Technicolor is a cowering Superman himself. Kryptonite! It’s so real in the fiend’s mind, it isn’t just blue and red, there’s yellow in there too. And Superman’s moving. He’s going, ‘That Kryptonite is strong. I can’t hold out much longer. My eyes growing dim!’ They’ll write research papers about the phenomenon, no doubt.</i></p><p><i>“Quality and design go hand in hand. Mario’s going to be selling Kryptonite, I’m going to be selling ‘Good Work’ and my beeper’s gonna stop ringing. I’d rather sell blanks than one of these stamps.”</i></p><p><i>“Do with it what you want, but like I told you, the police are looking for Kryptonite. And the Boogie Man is no doubt out there reconning. Dudes getting fucked up. Dimes dropping. Goldman’s out there holding his press conferences, and the jail filling up past capacity. Best stay low under the radar. Plus, they’ve got that new law, they can charge you now they link up a dead body to your brand, and catch you selling it. Listen to me, use one of these stamps or sell blanks like I do.”</i></p><p><i> “Blanks! Blanks are for nobodies!”</i></p><p><i>“And get yourself a new burner. You’re getting a lot of calls?”</i></p><p><i>“I had to turn the phone off.”</i></p><p><i>“You know everyone’s calling you.”</i></p><p><i> “Most everyone wants my Kryptonite.”</i></p><p><i>“Police get your number, they’ll call to set up a buy. ‘Hello, we’d like to buy some, err Kryptonite. Just a couple bags. We’re not cops. We’re fiends, yeah. We’re fiends, just looking for some bags of that, what’s that brand? Kryptonite. Yeah, Kryptonite.’ Then the next thing you know, they have you on the pavement, in a headlock with their knee digging in your back. And their bad cop breath enveloping you in a cloud of badness that don’t clear till years gone from your soul.”</i></p><p><i>While Enrique pretended to be pissed, he had to admit that was a worry he sometimes had. He had done time in juvie, and a couple overnights in the High Street lockup when caught up in sweeps, so he fully expected to find himself back inside for a fair stretch in the future. Build up some more street cred. But what Hernando said made sense. That was part of Hernando’s job—to keep trouble on someone else’s block, oversee the peace and ensure that his territory was productive, that enough profits went to those above him to keep him on the favored list.</i></p><p><i>They were all cogs in the machine, Hernando a bigger one than Enrique. Hernando tried to keep Enrique happy, but he also tried to keep him small to keep him safe. Hernando had four underlings who sold his product for him so he never sold retail himself. Besides those four, he was also an enforcer over four other dealers, including Mario, who was second in line for Hernando’s post. If Hernando moved up, Enrique would have to report to Mario, the fuck. Something needed to change there, for certain.</i></p><p><i>Enrique was an individual not well made for the work structure. Hernando was always warning him about his bags drawing too much attention, which was not good for anyone. But Enrique sometimes fancied the idea of being the independent hero, the wanted man like his father had been back in the day when his Last Call stamp proved to be just that for a few too many customers, though it was the rival Kings who got him, not the law. Enrique would be more elusive. He imagined police looking for the mastermind behind Kryptonite, and just when they are about to pounce, he’d switch brands, and they’d be back to ground zero. They would try to get to him through his customers, but his customers protected him because he always had the strongest stuff for their fiend cravings. They’d easily give up other dealers and shit brands, but they wouldn’t reveal the secret to their Man.</i></p><p><i>Maybe it was okay Mario was taking on Kryptonite. Let him take the fall. Enrique laughed to himself. Sucks to be you, he’d say to Mario when they perp-walked him down Lafayette Street to the courthouse. “You just don’t want to be looking at murder,” Hernando said. “That’s what I’m saying.”</i></p><p><i> Enrique was not one to dwell. He loved that Kryptonite stamp, but in the meantime, he had to get product out. After they had packed all of Hernado product, Enrique set about packing the rest for himself. For his bags he decided he would go simple like that special exhibit he had seen today at the Wadsworth Athenaeum. Enrique had been going to the Athenaeum since he was a kid when his Dad had worked there briefly as a security guard. He loved everything from the Egyptian Mummy to the crazy Revolutionary War battle scene that ran almost the length of the wall to the Hudson Bay Last of the Mohegans landscapes. He’s stars for hours at the Picasso. He loved the modern art and the impressionists. He even liked the crazy shit like the paper-mâché of the fat lady sunbathing in the lawn chair. It was all good.</i></p><p><i>Today the special exhibit had large white canvases with words boldly printed on them in black: PEACE. OPPRESSION. HATE. LOVE. ENVY. KNOWLEDGE. SEX. There was no subtlety. Stark statements. Made you think. That’s what art did. A part of him wished he had come up with the idea himself. HEROIN. SPOON. TOURNIQUET. HIGH. OVERDOSE. DEATH.</i></p><p><i>He set the letters up in the stamper they sometimes used and started stamping the blank bags. Two simple lines.</i></p><p><i>Dead</i></p><p><i>Men</i></p><p><i>Now that was a statement. Bold. Simple. Artistic. After he’s stamped them all, he packed, sealed and folded each bag, and then put a rubber band around ten, making a bundle. Every five bundles made a brick. $5 a bag. $30 a bundle. $125 a brick. Every bag kissed by the reaper.</i></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-pZNcM-YtoCY/YX8nMphxfJI/AAAAAAAAG_g/IxYKWVhUJYU4oIWtLhKVRHsLKe07CG0kQCLcBGAsYHQ/s640/IMG_0398.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="480" height="320" src="https://1.bp.blogspot.com/-pZNcM-YtoCY/YX8nMphxfJI/AAAAAAAAG_g/IxYKWVhUJYU4oIWtLhKVRHsLKe07CG0kQCLcBGAsYHQ/s320/IMG_0398.JPG" width="240" /></a></div><br /><p><br /></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-24409283097070331132021-10-28T20:40:00.001-04:002021-10-31T20:44:27.480-04:00City Scene<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-cg4oY0AahDI/YX84W-A0WvI/AAAAAAAAG_o/e6g-Am4g3fUKoYi5HARjYAimHIf6opOrgCLcBGAsYHQ/s2016/IMG_7086.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1512" data-original-width="2016" height="240" src="https://1.bp.blogspot.com/-cg4oY0AahDI/YX84W-A0WvI/AAAAAAAAG_o/e6g-Am4g3fUKoYi5HARjYAimHIf6opOrgCLcBGAsYHQ/s320/IMG_7086.jpg" width="320" /></a></div><br /><p><br /></p><p> A firefighter has already bandaged the patient’s head by the time I arrive in the fly car. The man sits on the front stoop looking like the fifer in the revolutionary war painting of the three marching wounded soldiers the way his head is wrapped. The firefighter points out the puddle of blood in the road and explains how witnesses say the man tripped on the curb and hit his head. “He has a pretty deep gash.”</p><p>“How’s his mental status. Is he all there?”</p><p>“No, he’s out of his mind. He’s on PCP.”</p><p>I nod. That would explain why the man mutters to himself and grabs at invisible bugs in the air.</p><p>“She’s on PCP, too.” A short woman in the pink dress stands next to the man. She opens his tattered wallet that she has fished out of his pants pocket. She takes out the only cash – a dollar bill—and puts it in her bra. </p><p>“Is that his wallet?”</p><p>She looks at me like she is not certain I am standing there — like maybe I am a seven foot lizard, or more reasonably just a hallucination. She goes back to looking through the wallet, slowly pulling out and staring at each card.</p><p>“Do you have his ID in there?”</p><p>The woman pays me no attention</p><p>“That’s his wallet,” the older man who called 911says. “Put that dollar back and find his ID and give it to the man. Give it to the man, now!”</p><p> “Are you okay?” I ask the patient. “Do you know where you are, sir?”</p><p>“Yes,” he says.</p><p>“Where’s that?”</p><p> “I’m good.”</p><p>“What’s your name? Do you know what day it is?”</p><p>“Yes.”</p><p>“Are you going to tell me?”</p><p>“I’m good.”</p><p>“Okay, we need to take you to the hospital as soon as the ambulance gets here. You have a head injury.”</p><p>He doesn’t respond. I don’t think he even knows someone is standing next to him. </p><p>The woman now has the man’s state card out. She leans down. “Beanie, Beanie, what’s your PIN number? Tell me your PIN number.” She holds the card out in front of him.</p><p>“Don’t tell her,” the old man says. “She’s going to take your money.”</p><p>“Beanie, your PIN number, tell me your pin number.”</p><p>I can hear the ambulance siren approaching. “We’re going to take you to the hospital. You need to get that head looked at.”</p><p>“I’m good.”</p><p>I take my cell phone out and turn the camera on in the selfie mode. “Look that’s you,” I say. “You’re all mashed up.”</p><p>He looks at the person on the screen — a man with a bloody bandaged face, but says nothing.</p><p>“You fell and busted your head. Look at all the blood in the road.”</p><p> “I’m not going to the hospital.”</p><p> “That’s okay. We’ll take you to the ER instead. That’s the better place for you.”</p><p>“Nothing wrong with me. I’m good.”</p><p>The ambulance stops in the road, its red lights flashing.</p><p>I motion to the medic in the passenger seat to come over. I am going to tell him his patient has a head injury, and is also on PCP. It will be a challenge getting the man on the stretcher.</p><p>The medic rolls down the window, “Can’t,” he says. “Dogs.”</p><p>A brown and white pit bull is jumping up against the driver side door. In the middle of the road a second pit bull stares at the ambulance front grille.</p><p>The medic shrugs.</p><p>“Damn,” the old man says. “That girl left the gate open again.”</p><p>“Beanie, Beanie,” the woman whispers. Her lips are inches from the man with the bandaged head’s ear. “Tell me you PIN number. Tell me your PIN number, Beanie.”</p><p><br /></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-18574102140712563152021-10-21T20:44:00.001-04:002021-10-31T20:46:54.692-04:00Reasonable People<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-f8-1Xi2rmt4/YX848C7tp4I/AAAAAAAAG_w/_AP9rfiMR5I4UdwkdwUqS0ScfQiPO_bgACLcBGAsYHQ/s850/love.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="511" data-original-width="850" height="192" src="https://1.bp.blogspot.com/-f8-1Xi2rmt4/YX848C7tp4I/AAAAAAAAG_w/_AP9rfiMR5I4UdwkdwUqS0ScfQiPO_bgACLcBGAsYHQ/s320/love.jpg" width="320" /></a></div><br /><p></p><p>When I started as a paramedic in Hartford in 1995, I thought drug users had character flaws and belonged in jail. Last week at a panel discussion in Hartford I stood up before National Drug Control Policy Acting Director Regina LaBelle, United States Senator Richard Blumenthal, United States Representative John Larsen, and the Mayor of Hartford Luke Bronin. I urged them to consider decriminalization of drug use, creation of a safe, regulated drug supply and establishment of safe injection sites. I told them I believed the War on Drugs had been a failure and that while we all recognized now that this crisis is a public health problem, not a law enforcement problem, therefore, we needed to take major Public Health ACTION. People, who we recognize suffer from the medical disease of addiction, have no choice but to go to Park Street or some other place where illegal drugs can be had. They buy the drugs that are offered, but they have no way of knowing the dose they are getting. Fentanyl test strips can tell a user if fentanyl is present, but not how much fentanyl is in their $3 bag. Dealers have not found a way to mix the drugs to guarantee a predictable dose. Fentanyl due to its tendency to clump results in the chocolate chip cookie syndrome, except you have no way to tell that your bag contains a giant chip (clump) of fentanyl that can kill even the most experienced user if they use alone and are not found before the fentanyl stops their breathing and then hypoxia stops their heart.</p><p>It used to be that most people who overdosed did so because of tolerance issues –they just got out of jail or rehab or ended a period of prolonged abstinence and when they tried to use their usual amount, they overdosed because their tolerance was low. Now it seems that overdoses are random. While people are still overdosing due to tolerance issues, many steady users are overdosing because they take what appears to be their normal amount, but their same amount of white powder contains an unexpectedly higher (and undetectable) percentage of fentanyl and they overdose and die if no one finds them in time.</p><p>From a public health point of view if we want to save lives, we have to find a way to ensure people are able to accurately know the dose they are taking. Trying to get fentanyl off the street through interdiction at the border has not worked. I suggest a new approach where we offer a safe regulated supply to qualified users. Instead of buying street fentanyl with its unpredictable dosing people in the program can go to a clinic similar to a methadone clinic where they can get medicinal heroin or dilaudid which they can consume in the presence of a health care provider who can also talk with them about their medical and social issues. This approach is evidence-based and has worked successfully in other countries from Canada to Portugal.</p><p>Back during prohibition many people died or were blinded or suffered other serious maladies due to bootleggers adding wood alcohol to the liquor they sold. What is happening today is similar but on a far larger scale. The corpses pile high with no end in sight. We have the ability to change this deadly trajectory. Methadone and suboxone work. So also would legalized regulated and prescribed heroin and dilaudid. </p><p>If you were charged with finding a way to end the opioid death toll, what would be your best bet? Have a person buy their dope on Park Street and inject down in the bushes of the ravine off Park Terrace where the next day I stand over their cold body and call the time? Ashes to Ashes. Dust to Dust. Or have that person use in a clean well lighted room where the dose is measured and the health care provider watching over them has naloxone in hand if needed, as well as a listening ear and the ability to help them find services if they are ready to accept them?</p><p>If your daughter was addicted (following a car accident, or simple experimentation) and today has a choice between going to Park Street and buying two $3 bags of Devil’s Son containing who knows what dose of fentanyl or going to a safe consumption site and receiving medical-grade heroin, what would you want for her? </p><p>While years ago, I would have not considered this, today, based on what I know about addiction, based on the stories told me by my patients who use drugs, based on the love we should all hold in our hearts for the health and people of our communities, based on the history of what has not worked and what has, I think it is time reasonable people begin this discussion. Decriminalization. Safe Supply, Safe Injection Sites. Let’s start saving lives.</p><p><br /></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-61759272222245310472021-10-14T20:47:00.001-04:002021-10-31T20:49:13.120-04:00Emerald City<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-n4XSHSKq9R0/YX85Zf9fs5I/AAAAAAAAG_4/L8HHsW7L30UuAgTTr15RhPIBME6pEKyDwCLcBGAsYHQ/s850/emerald.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="588" data-original-width="850" height="221" src="https://1.bp.blogspot.com/-n4XSHSKq9R0/YX85Zf9fs5I/AAAAAAAAG_4/L8HHsW7L30UuAgTTr15RhPIBME6pEKyDwCLcBGAsYHQ/s320/emerald.jpg" width="320" /></a></div><br /><p><br /></p><p>She took the Dilaudid pill a friend offered her twelve years ago when she was sixteen. Her sister had recently died and her young life, filled with depression and anxiety, had lost its only source of light. The pill made her feel well in a way she had never felt before. She liked who she was when she was on opioids. She had friends. She felt joy again. Four years later she tried heroin for the first time because it was so cheaper and more accessible. Two years later she graduated to injecting. She’s been to rehab five times with no success. She’s tried methadone and suboxone. No luck. She is on Vivitrol now, but as the monthly shot wanes, she always finds her way back to the city. She injects herself with heroin because it soothes her anxiety and cushions her in a cloud of calm. She injects cocaine because it makes her feel invincible.</p><p>The guy she was with in the hotel room called 911 when he came out of the bathroom and found her unresponsive on the carpet with the two syringes on the bureau and the torn heroin bags branded “Emerald City” and the small plastic bag with some cocaine powder still in it. </p><p>She was blue and agonal with vomit on the rug next to her. With some stimulation, bagging and a small titrated amount of naloxone, we brought her around. She didn’t want to go to the hospital at first, but we convinced her of the need to be evaluated. Her heart was racing in the 140’s and her oxygen saturation was only in the high 80’s. We were concerned she may have aspirated.</p><p>The now silent man fetched her purse and slippers and we put them on the back of the stretcher. With a blanket I covered up her tattooed back and shoulders, but not before complimenting her on her artwork. The artist had drawn a magnificent mountain top with elaborate etchings of trees, eagles, deer, and stars, along with the words: “The journey to the top is my soul.”</p><p>This is the third time she has overdosed, but the first in three years. I give her my harm reduction talk about the dangers of fentanyl, how it mixes poorly so you never know how much you are actually getting in each $3 bag. None, a regular dose or a lethal one. It was a good she was not alone.</p><p>We talk more. She answers my question about how she got started, and she tells why it is so hard to quit. When I ask her who the man in the room was, she just shrugs. Some guy. I get her demographics. She lives in a small town forty minutes from the city. She asks if she has to give me her emergency contact.</p><p>“No,” I say. “Not if you don’t want to give it.”</p><p>“I don’t want my parents to know.”</p><p>“They don’t have to. It’s your choice.”</p><p>“I don’t want them to lose faith in me.”</p><p>I ask her about her relationship with them and she begins crying. “They love me,” she says.</p><p>She tells me how supportive of her they have been, how much they care for her and want her to win her battle.</p><p>At the hospital, I tell the girl’s story to the nurse but the nurse just rolls her eyes. It is busy in the ER and she has no time beyond a basic report.</p><p>I wonder where the girl is tonight. Is she home with her parents? What will they think when she asks to go out? Will she just walk the quiet small town streets, struggling for the strength to stay the sober course, to keep her journey on the straight and narrow. Or is she back here in the city, at another hotel with a nameless man? The needle in her arm, the heroin easing her skittishness, keeping the darkness at bay, the cocaine rush making her feel invincible — up on the mountaintop now, her soul dancing under the stars? </p><p><br /></p><p>.</p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-66910711464701191522021-10-08T20:49:00.001-04:002021-10-31T20:51:30.102-04:00Hoop Dreams<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-UC5LVpA0bNs/YX86AufzUjI/AAAAAAAAHAA/uKv5YQt5Hr0s6u5Z93o2pber9glNE1oZwCLcBGAsYHQ/s653/hoop.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="387" data-original-width="653" height="190" src="https://1.bp.blogspot.com/-UC5LVpA0bNs/YX86AufzUjI/AAAAAAAAHAA/uKv5YQt5Hr0s6u5Z93o2pber9glNE1oZwCLcBGAsYHQ/s320/hoop.jpg" width="320" /></a></div><br /><p></p><p><span style="background-color: white; font-size: 16px;"><span style="font-family: inherit;">I am sixty-three years old, six foot eight. I used to be six nine and a half, but life has beaten me down. Over thirty years in EMS has flattened my spine to the point that some days I can barely feel my legs. I have no business being back on a basketball court, but I eagerly lace up my new Lou Williams’s size 14s, put on my Washington Generals tank top and head to the park where I will play a pickup game with men half and even one third my age. I don’t have a lot going for me except my height. I am slow, not just in speed, but reaction time. The youngers have found they can attack me with jukes and jives and I am too slow to block their shots when they come at me, and if I go out to challenge their outside shots, they fake me and drive around me, rising to the rim before I even get turned back toward the basket. My balance has already caused me to fall once chasing a ball, scraping my knee, elbow and shoulder and nearly falling another time except for a helping hand of another player to grab me and steady me. I can’t jump. Once I could dunk. Now while I stand and can hold onto the bottom of the net with both hands, I can’t jump high enough to touch the rim, while the diminutive point guard on the other team does pull ups on it. And while I may be in okay shape for sixty-three, I need to sub out frequently because I don’t have the lungs of a thirty-year old. But I am not completely without value. If I find the right spot I can hit a jumper. While slow, no one can block my hook shot and sometimes if I run the court on a fast break, while my defender slacks, I can get open for a pass with an easy layup.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">That’s what I play for — to make the baskets. I try to tell my daughter of the joy I feel when the ball rips through the net. I know each basket I make could be my last. I could fall and break my hip. I could take an elbow to the chest and break my ribs, I could fracture my hand grabbing a rebound. I could die in any of a number of ways I have seen people die in my work as a paramedic.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I stopped playing basketball years ago because I did get injured. I broke a finger going up for a rebound, and while I worked through it, it was painful and I had to develop a new way of holding the IV catheter when I tried to cannulate a vein. Once, our company, which does standbys at the civic center was granted use of their court at noon one day. We played a game between company divisions in front of 16,000 empty seats. I scored twenty points, but took a headbutt to the chest in a scramble for a loose ball, which I believe may have cracked my sternum as I couldn’t sit up in bed for over a month without holding a pillow to my chest, and if I tried to do a pushup, I felt as if my chest would crack in two. I also dislocated my pinky diving over the courtside chairs trying to save a ball from going out of bounds. That was my last game for almost twenty years. I couldn’t risk getting hurt at basketball and missing extended time at work. I had a family to feed.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">But taking my daughter to her basketball games and practices in recent years has rekindled the fire. It also helps that I have a desk job that provides most of my income with my street time now only 10 hours a week, I am no longer entirely dependent on my physical health to get my paycheck. While my daughter practices with her team inside the gym, I shoot alone on the outside playground. In the rain. Just like when I was a kid, I imagine myself in the NBA with the clock running down and the ball in my hands, and my teammates depending on me.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I should probably be doing something else with my time, like writing my next book or producing more blog posts or working on a work project or lifting weights, running, stretching or swimming, instead of dribbling a basketball, shooting 50 free throws and then 25 three point shots, but spending a good part of the time chasing after errant rebounds.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Sometimes my daughter will come out and shoot with me. We had a free throw contest the other day. First to 10. I missed my first shot, then she hit twelve in a row. My daughter is 13 and really good. Last Sunday, as the only 8th grader on a high school travel team, she knocked down three threes in just a few minutes time, where a year or so ago she could barely make the distance. “Dad,” she tells me. “I love the weekends because I get to play basketball.” She is talking about a game with officials on the floor of the Bristol Sports Armory and other local arenas where she and her older teammates will play against challenging teams, and win or lose, there will be moments of victory (as well as defeat), memorable moments of a great pass, a spin move to the hoop, or watching a three rip through the net.</span></p><figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-4-3 wp-has-aspect-ratio" style="background-color: white; box-sizing: inherit; font-family: lato, lato, "helvetica neue", helvetica, arial, sans-serif; font-size: 16px; margin: 0px 0px 1em;"><div class="wp-block-embed__wrapper" style="box-sizing: inherit; position: relative;"><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="480" loading="lazy" src="https://www.youtube.com/embed/-uLElHtH0u4?feature=oembed" style="box-sizing: inherit; max-width: 100%;" title="333s" width="640"></iframe></div></figure><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I wonder what she will do when she grows up. I hope she will find work that will bring her as much happiness as basketball does. That’s why I have always loved being a paramedic. Sometimes on calls, it is just like playing sports before a crowd Pressures on, eyes are on you, you have to perform. You can’t let the pressure get to you. There is the same camaraderie with your crew or your partner as you had with your team. I try to teach my daughter that sports is about life lessons, things you can use in the real world, but sports, I am realizing is also an end in itself, a pure joy. Sixty-three, slow, old, hard of hearing, tired, weak legs, a cough that rattles the earth itself, but I grab the rebound, I dribble to the corner, I turn and shoot. The ball arches through the air. It rips through the net.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I am alive.</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-339408757486697862021-10-06T20:52:00.001-04:002021-10-31T20:53:43.867-04:00Dopesick<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-UGRTHK1oav8/YX86gkyO3DI/AAAAAAAAHAI/lmdHbBovTeoY_Wj-ZIOKt3LtrIaplsvbQCLcBGAsYHQ/s1511/dopesick.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1511" data-original-width="850" height="320" src="https://1.bp.blogspot.com/-UGRTHK1oav8/YX86gkyO3DI/AAAAAAAAHAI/lmdHbBovTeoY_Wj-ZIOKt3LtrIaplsvbQCLcBGAsYHQ/s320/dopesick.jpg" width="180" /></a></div><br /><p></p><p><br /></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"><a href="https://www.hulu.com/series/dopesick-227de06a-d3d4-42e0-9df1-bb5495e1738d" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">“Dopesick”</a> is a new eight-episode series dramatizing the start of the opioid overdose epidemic that originated with Purdue Pharma’s marketing campaign for oxycodone .The series is populated with a fictional cast of characters, including a country doctor (Michael Keaton), a young woman injured in a coal mining accident and her parents who struggle to understand her addiction, an earnest young drug salesman, two US attorneys and a DEA agent (Rosario Dawson) who fight to combat the powerful drug company and Purdue’s bought and paid for allies in the FDA and Congress. I’ve seen seven of the eight episodes, and I can tell you this is riveting TV that will move, startle and anger you, and I hope by the final episode, inspire you to help change this country’s approach to the epidemic. The producers and writers did an amazing job taking the facts of the epidemic and turning them into compelling drama that should engage a wide audience.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">What Purdue Pharma did was criminal, and it unleashed on this country a tragedy of epic proportions. As a paramedic, with each corpse I stand over and run my six-second strip of asystole (flatline) before announcing the time of their death presumption, my own rage grows. This series aims squarely at the Sackler family, in particular Richard Sackler (Michael Stuhlbarg), as the bad guys, but also directs its wrath at FDA and DEA officials who went easy on Purdue before joining Purdue in high paying private sector jobs. Why no one from Purdue has ended up behind bars while users, who sell $3 bags to support their addiction, are locked away for years is stunning to me. It is a testament to the power and the influence of money on our political system.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Unfortunately, exposing and damming Purdue Pharma doesn’t end this epidemic. The dead remain in their graves with countless more ghosts joining them with no end in sight, souls lost forever to the living world. There are more parts of this epidemic to follow, the rise of heroin after Purdue comes out with a tamper-resistant oxycontin, and the current and most dangerous wave of fentanyl poisoning the drug supply and turning each hit into a game of Russian roulette with the reaper.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Dopesick should convince those who watch and hopefully those in power that most of those affected by this crisis were afflicted through no fault of their own. They got hurt or sick and trusted their doctors and trusted their regulators and elected officials to protect them, but instead they suffered addiction, stigma, jail, failed rehabs and death.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">We have a chance in America to fix this and end the deaths if we pursue the scientifically evidence based avenues of decriminalization, safe injection sites, medical opioids, and a safe legal drug supply. Instead we are likely to get more arrests, more jail time, and more deaths by following old and failed, but politically expedient policies of the past.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Watch Dope Sick. Follow Michael Keaton’s journey, feel the heartache of parents, witness the Richard Sackler dark villany, cheer for Rosario’s passion. Then commit yourself to educate your neighbors and community about stigma, harm reduction and call for a shift in resources from the criminal war on drugs to a humane public health approach based on science.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Dopesick premiers on Hulu on October 13, 2021. It is loosely based on the book <a href="https://www.amazon.com/Dopesick-Dealers-Doctors-Company-Addicted/dp/0316551309/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1633544926&sr=1-1" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">Dopesick</a> by the journalist Beth Macy.</span></p><p style="background-color: white; box-sizing: inherit; font-family: lato, lato, "helvetica neue", helvetica, arial, sans-serif; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://youtu.be/JYU1kzGn4rk." style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">https://youtu.be/JYU1kzGn4rk.</a></p><figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio" style="background-color: white; box-sizing: inherit; font-family: lato, lato, "helvetica neue", helvetica, arial, sans-serif; font-size: 16px; margin: 0px 0px 1em;"><div class="wp-block-embed__wrapper" style="box-sizing: inherit; position: relative;"><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="360" loading="lazy" src="https://www.youtube.com/embed/JYU1kzGn4rk?feature=oembed" style="box-sizing: inherit; max-width: 100%;" title="Dopesick Teaser | Hulu" width="640"></iframe></div></figure>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-10816093679432840032021-09-29T20:54:00.001-04:002021-10-31T20:55:33.200-04:00origin Story<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-7iu95lFATF0/YX868VkGaLI/AAAAAAAAHAQ/i1yHHKyFgBY5M-Q3uWjOhBuz0L2ZKIvSACLcBGAsYHQ/s2048/IMG_3184.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1967" data-original-width="2048" height="307" src="https://1.bp.blogspot.com/-7iu95lFATF0/YX868VkGaLI/AAAAAAAAHAQ/i1yHHKyFgBY5M-Q3uWjOhBuz0L2ZKIvSACLcBGAsYHQ/s320/IMG_3184.jpg" width="320" /></a></div><br /><p></p><p><span style="background-color: white; font-size: 16px;"><span style="font-family: inherit;">For many of us in EMS, our origin story began with watching the TV show Emergency. The decent paramedics Johnny and Roy, the wise Drs. Brackett and Early, and the beautiful unflappable nurse, Dixie McCall. Together they stood for all that was good in the world. They were role models for us in showing us a path to lead our lives as rescuers.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When we entered the workforce, or at later times, contemplated the other work we were doing, and wondered if there was something more meaningful, the example of Emergency was always there for us.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I came to EMS later than most. I was in my early thirties. I had been working in government/politics for a United States Senator, and with his defeat in 1988, I was at a crossroads. I liked the man I worked for – US Senator Lowell Weicker. He was a liberal Republican who was not afraid to buck his own party if he thought his actions would benefit the people of his state and country. He was a member of a group of moderate Republicans like Charles Mathias of Maryland, Jacob Javits of New York, and Ed Brooke of Massachusetts who crafted compromises both parties could live with. Sadly today, as William Butler Yeats warned in his poem “The Second Coming,” the middle did not hold.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><em style="box-sizing: inherit;"><span style="font-family: inherit;">“Things fall apart; the centre cannot hold;<br style="box-sizing: inherit;" />Mere anarchy is loosed upon the world,”</span></em></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Politics today is no longer about making good policy, it is about making political points in a battle for personal power. Everyone is partisan. Weicker was defeated by Joseph Lieberman, a Democrat who ran attack ads that distorted Weicker’s record, while Weicker preferred positive ads believing the people understood he was their champion. We didn’t know it then, but the world was changing. There was no FOX cable news channel then. No MSNBC. No internet. No Facebook or Twitter, but the seeds of the future were already being sown.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I never really cared for the political life. I could have stayed in Washington and became an aide to another Senator or joined an interest group or lobbying firm. Instead, I (full of beer and passion) announced at a going away party for the Weicker staff that I was going to become an EMT, and then having said it aloud, I had to follow up on it. And so began my EMS odyssey. Even when Weicker ran for and was elected governor and I worked on his campaign and served as a speechwriter and executive assistant at the state health department for his four year term, I continued to work as an EMT at night, while thinking about going to paramedic school.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">The other day I came across a collection of quotes I had put together at that time (1992). The quotes represented what I thought about life at the time. They contained song lyrics, passages from books, poetry and culture, along with illustrations. I saw one quote I had forgotten about, one that I remembered finding in a book by the great oral historian Studs Terkel.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><em style="box-sizing: inherit;"><span style="font-family: inherit;">“The fuckin’ world’s so fucked up, the country’s fucked up. But the fireman, you actually see them produce. You see them put out a fire. You see them come out with babies in their hands. You see them give mouth to mouth when a guy’s dying. You can’t get around that shit. That’s real. To me that’s what I want to be.”</span></em></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"><em style="box-sizing: inherit;">I worked in a bank. You know, it’s just paper. It’s not real. Nine to five and its shit. You’re looking at numbers. But I can look back and say, “I helped put out a fire. I helped save someone.’ It shows something I did on this earth.”</em><br style="box-sizing: inherit;" /></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">-Tom Patrick, Brooklyn firefighter quoted in Studs Terkel’s <a href="https://www.amazon.com/Working-Studs-Terkel/dp/1567319955/ref=sr_1_6?crid=U5ZENMQBPEE8&dchild=1&keywords=working+studs+terkel&qid=1632948212&sprefix=working+studs%2Caps%2C234&sr=8-6" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">Working</a>.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I believe that quotation, as much as all the episodes of <em style="box-sizing: inherit;">Emergency</em>, set me on my ultimate life’s path as an emergency medical responder. When Weicker left office in January of 1995, the next day I was on the streets of Hartford with a paramedic patch on one shoulder and an American flag on the other.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Now at sixty-three, in a world that seems to be threatening to fall apart, from the hateful politics of the our times, to the roof of my house, to my battered 200,000 mile plus sedan, to my own health no longer that of a young man, here I stand, still putting on my uniform and going in to work to answer the call.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I did seventeen 911 responses in a ten hour shift last Friday, and when I came home I just sat in front of the TV with my wife and daughter and ate a late dinner before going to bed to sleep the sleep of the weary.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I wish all jobs were like ours, where the oath is to do no harm, to help others, to make the world a better place.</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-30683204902857690912021-09-22T20:55:00.001-04:002021-10-31T20:57:46.419-04:00Xylazone- Mind F<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-j-gCjCZpsOg/YX87dd28xvI/AAAAAAAAHAY/8Lgr3yVvy_At4HcWlgp51gkcP0KJ1JZAQCLcBGAsYHQ/s1536/devil.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1536" data-original-width="1152" height="320" src="https://1.bp.blogspot.com/-j-gCjCZpsOg/YX87dd28xvI/AAAAAAAAHAY/8Lgr3yVvy_At4HcWlgp51gkcP0KJ1JZAQCLcBGAsYHQ/s320/devil.jpg" width="240" /></a></div><br /><span style="font-family: inherit;"><br /></span><p></p><p><span style="font-family: inherit;"> <span style="background-color: white; font-size: 16px;">Xylazine, a horse tranquilizer, has been increasingly found as an adulterant in the East Coast street supply of fentanyl. In 2019 in Connecticut, xylazine and fentanyl were found together in 71 overdose deaths. There were 141 deaths of this combination in 2020, and in 2021, through August with still many cases outstanding, the number has risen to 172.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">In Puerto Rico dealers began mixing xylazine with heroin in the early 2000s. While xylazine has not been the subject of much human research and is definitely not approved for human use, it is believed to produce prolonged sedation and likely works synergistically with opioids to create a longer high. This is significant because fentanyl has largely replaced heroin along much of the east coast, due to its economic advantages for dealers. Fentanyl typically lasts 4-6 hours while heroin lasts 6-8 hours. Fentanyl’s shorter duration requires people to use more often to fight off withdrawal. It is speculated that xylazine’s longer sedative effects may help fight off withdrawal, and enable users to go longer between doses. The high produced by xylazine with fentanyl also, according to some users, more closely produces the nod associated with heroin, which some users prefer to the potent fentanyl rush. Other users, however, seek to avoid it because it makes them feel like zombies, trapped in a haze that lasts for hours.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">There are significant drawbacks to xylazine. Most commonly xylazine, which may depress cells’ ability to handle oxygen, has been known to cause bad skin ulcers, as well as hypotension and bradycardia. Xylazine may potentiate the respiratory depression of fentanyl and make someone more likely to die from overdose. In other words, the xylazine may be enough to make someone severely respiratory depressed from fentanyl, completely stop breathing (not that fentanyl needs much help in this department), which will mean death if someone doesn’t arrive soon with naloxone to resolve the fentanyl induced respiratory depression. Some have said xylazine makes the user naloxone resistant, but I don’t buy that. Naloxone will still work on the fentanyl, enabling the person to breathe on their own, while still leaving them tranquilized with the xylazine.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">If you are buying a bag of heroin/fentanyl on the street in Hartford, the guy taking your 4 dollars is unlikely to know whether or not there is xylazine in the powder. An experienced user may be able to detect the presence of xylazine based on how it makes them feel. It has been reported in Philadelphia that some dealers advertise the xylazine adulterated mix as “tranq dope,” but I have not heard that is the case here in Hartford based on my limited connections with users and harm reduction advocates. I recently asked a friend who now works as a bagger for a local dealer (in return for coffee, beverages, snacks, along with a low wage and discount on his fentanyl ($20 a bundle of ten instead of $30)), and he told me that his dealer does not use xylazine in his recipe. He said that he has previously purchased bags from other dealers that he thinks likely had xylazine because they caused him to suffer severe ulcerations and also made him feel excessively tired and out of it.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">His account squares with what we have seen on the street, and what we had previously believed might have been PCP mixed with fentanyl. (PCP while making some users crazed, leaves others catatonic.) One user called the fentanyl mix she was using “mind fuck” because it made her feel like she was trapped in her own body. Not being able to test the drugs they used, these instances could have been xylazine or they could have been some other unknown additive.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">The bottom line is the drug supply is increasingly more dangerous, not just causing more deaths, but significantly harming users’ health as well.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">While we offer users health services, naloxone and syringe exchange, if we are serious about lessening the deaths, we need to address the biggest culprit behind the slaughter — our toxic drug supply. It is time to consider controlled legalization of pharmaceutical opioids. Get rid of the poisons like xylazine and poorly mixed fentanyl batches, bring users in from the cold and allow them to use in safe injection facilities with medical and social services who can offer avenues to recovery. If we truly believe our rhetoric that addiction is a medical and not a criminal problem, and we want to save lives, this is the logical next step. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368046/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">The Emerging of Xylazine as a New Drug of Abuse and its Health Consequences among Drug Users in Puerto Rico</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://pubmed.ncbi.nlm.nih.gov/24769343/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://injuryprevention.bmj.com/content/27/4/395" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Increasing presence of xylazine in heroin and/or fentanyl deaths, Philadelphia, Pennsylvania, 2010–2019</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://www.thedailybeast.com/horse-tranquilizer-xylazine-keeps-showing-up-in-fentanyl-drug-overdoses" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">This Horse Tranquilizer Keeps Showing Up in Human Drug Overdoses</span></a></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-63441740076535532892021-09-18T20:57:00.001-04:002021-10-31T21:02:44.417-04:00Graveyard<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/--9s0t3TI1Ok/YX88OLDIHiI/AAAAAAAAHAg/4Eu8WMQfxRAa-XqmpeSXSKAlKcIJh2ndQCLcBGAsYHQ/s640/grave.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="295" data-original-width="640" height="148" src="https://1.bp.blogspot.com/--9s0t3TI1Ok/YX88OLDIHiI/AAAAAAAAHAg/4Eu8WMQfxRAa-XqmpeSXSKAlKcIJh2ndQCLcBGAsYHQ/s320/grave.png" width="320" /></a></div><br /><span style="font-family: inherit;"><br /></span><p></p><p><span style="font-family: inherit;"> </span><span style="background-color: white; font-family: inherit; font-size: 16px;">I came to work the other day and saw a chilling site in the parking lot. Ambulance 911 — the ambulance that was assigned to me for many years when I worked the 5:30-17:30 shift, the ambulance that had been my EMS home — sat battered and wrecked in a line with other battered and wrecked ambulance and fly cars in our lot that at times seems like an emergency vehicle repair/burial yard. It sent a chill through me. (Fortunately, I found out the crew involved in the rollover accident was okay.)</span></p><figure class="wp-block-image size-full is-resized" style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1em;"><span style="font-family: inherit;"><img alt="" class="wp-image-22579" height="320" loading="lazy" sizes="(max-width: 240px) 100vw, 240px" src="https://secureservercdn.net/198.71.233.52/395.bed.myftpupload.com/wp-content/uploads/2021/09/IMG_6357-rotated.jpg" srcset="https://secureservercdn.net/198.71.233.52/395.bed.myftpupload.com/wp-content/uploads/2021/09/IMG_6357-rotated.jpg 480w, https://secureservercdn.net/198.71.233.52/395.bed.myftpupload.com/wp-content/uploads/2021/09/IMG_6357-225x300.jpg 225w, https://secureservercdn.net/198.71.233.52/395.bed.myftpupload.com/wp-content/uploads/2021/09/IMG_6357-300x400.jpg 300w" style="border-radius: inherit; border: 0px; box-sizing: inherit; height: auto; max-width: 100%;" width="240" /></span></figure><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">EMS work is not safe. I know coworkers who wear bulletproof vests; others are meticulous in their infection control habits, always gloving and gowning up and washing their hands thoroughly. But if you really want to protect yourself in EMS, you should be wearing a crash helmet and a St. Christopher cross around your neck.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Here is a post I wrote back in 2006, describing an incident where I almost died. In the years since, I have had other close calls, but still nothing significant as far as ambulance safety or dispatch protocols has changed. We still travel lights and sirens too much, both to calls and from the scene to the hospital. Please be safe out there.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://medicscribe.com/2008/03/i-almost-died-today/">I Almost Died Today</a><br /></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><br /></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-84316010754018872252021-09-14T21:02:00.001-04:002021-10-31T21:04:52.043-04:00Pediatric Posioning<p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-Z7mRiQWV8l4/YX89ICBLXSI/AAAAAAAAHAo/5Cx9T3O-t4spODYXvBufFMnLRSgiYBdYQCLcBGAsYHQ/s448/ped.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="336" data-original-width="448" height="240" src="https://1.bp.blogspot.com/-Z7mRiQWV8l4/YX89ICBLXSI/AAAAAAAAHAo/5Cx9T3O-t4spODYXvBufFMnLRSgiYBdYQCLcBGAsYHQ/s320/ped.jpg" width="320" /></a></div><span style="font-family: inherit;"><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"><br /></span></p>You’re called to an urgent care center on a priority one. The nurse is holding the front door of the center open for you and directs you back to a treatment room, where a PA and another nurse are providing ventilations to a two year-year-old. The story they tell you is the the child fell off the couch and was not acting right. His mother drove him to the urgent care center where they found the child somnolent and hypoxic. The PA is questioning a head injury. The child has no pertinent medical history and there was no seizure activity described at any time. The child’s pupils are smallish, but equal under the bright light of the exam room. The mother sits quietly in a chair in the room. She can’t be more than twenty herself and seems detached from the emotion in the room.</span><p></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">You quickly reexamine the child and see no bruising. While your partner straps a pedi-mate to the stretcher to secure the child, you take over bagging and find good compliance. The pulse oximeter probe you attach to the child’s toe shows a pulse saturation of 93%. The child’s lungs are clear. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">While your partner drives, you and your student continue bagging. You reexamine the child’s pupils, tuning off the compartment lights and using your penlight. The pupils are definitely pinpoint. You try 0.1 mgs of Naloxone through the IV your student has gotten in the child’s hand. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">My goodness. Within a minute, the child is breathing on his own, his eyes are open and he is looking about the inside of the ambulance like he has been transported to a spaceship out of close encounters of the third kind.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">You ask the mom, who is riding in front with your partner, if the child could have gotten into anything. The mom you notice then is asleep, head nodded forward. You reach through the cab window and shake her shoulder, “Hey!” She looks up, half awake, as you ask, “Any chance the baby could have gotten into anything? Any pills or powders about the house?”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">She shrugs. “What?”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“Are there any opioids loose in your house?”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">She doesn’t understand.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“Heroin, Fentanyl, methadone, suboxone, oxycodone, percocet, vicodin, morphine, cough syrup…”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“I’m on suboxone,” she says finally.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“Okay,” you say, “We’ll talk more.”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">At the hospital she will talk with more people than you. The police department and the Department of Child and Family Services will interview her after the child tests positive for opioids.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">***</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">In Connecticut, EMS responders are required by law to report all suspected opioid overdoses to the Connecticut Poison Control Center (CPCC). In the last two years the CPCC has received numerous reports from EMS of children 3 and under overdosing on opioids, reports that have been confirmed by hospital toxicology lab results. Positive tests have included fentanyl, cocaine, oxycodone, methadone and general opioid. Additionally, the CPCC has also received reports from hospitals of similar cases where the parents brought the children directly to the hospital. In 2020, two Connecticut infants died of fentanyl poisoning, including one who was found with a heroin bag branded “Skittles.” </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When responding to obtunded children in today’s world, medical professionals should always keep opioid poisoning at the front of their mind when considering their differential diagnosis.</span></p><figure class="wp-block-embed is-type-wp-embed is-provider-nbc-connecticut wp-block-embed-nbc-connecticut" style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1em;"><div class="wp-block-embed__wrapper" style="box-sizing: inherit; position: relative;"><span style="font-family: inherit;"><iframe class="wp-embedded-content" data-secret="g4wSrjrHoU" frameborder="0" height="304" marginheight="0" marginwidth="0" sandbox="allow-scripts" scrolling="no" security="restricted" src="https://www.nbcconnecticut.com/news/local/oxford-mom-arrested-after-baby-dies-of-drug-overdose/2345916/embed/#?secret=g4wSrjrHoU" style="box-sizing: inherit; max-width: 100%;" title="“Oxford Mom Arrested After Baby Dies of Drug Overdose” — NBC Connecticut" width="600"></iframe></span></div></figure><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://www.nbcconnecticut.com/news/local/father-charged-after-infant-overdoses-on-fentanyl-in-vernon/2260255/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Father Charged After Infant Overdoses on Fentanyl in Vernon</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://www.wtnh.com/news/connecticut/doctors-see-alarming-trend-of-kids-brought-into-er-for-drug-overdoses-fentanyl-in-their-system/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Doctors see alarming trend of kids brought into ER for drug overdoses, fentanyl in their system</span></a></p><p><span style="font-family: inherit;"><span style="background-color: white; font-size: 16px;">In 2017, I wrote a blog post calling on dealers to stop using stamps with children’s characters on them and instead use skulls. Here is the link to</span><span style="background-color: white; font-size: 16px;"> </span><a href="https://medicscribe.com/2017/05/hello-kitty/" style="box-sizing: inherit; color: black; font-size: 16px; transition: all 0.1s linear 0s;">Hello Kitty</a><span style="background-color: white; font-size: 16px;">.</span> </span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-11313962662457372992021-09-08T21:04:00.001-04:002021-10-31T21:06:17.507-04:00Safe Supply<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-Fc9_4jFVUdw/YX89fN8GybI/AAAAAAAAHAw/qH_IFcq60TEhM4t10J5tyxYZqcGIKFV9wCLcBGAsYHQ/s640/bio.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="640" data-original-width="480" height="320" src="https://1.bp.blogspot.com/-Fc9_4jFVUdw/YX89fN8GybI/AAAAAAAAHAw/qH_IFcq60TEhM4t10J5tyxYZqcGIKFV9wCLcBGAsYHQ/s320/bio.jpg" width="240" /></a></div><br /><span style="font-family: inherit;"><br /></span><p></p><p><span style="font-family: inherit;"> <span style="background-color: white; font-size: 16px;">In the last two days, there were two big news stories about famous people dying of suspected opioid overdoses. One involved the death of one of my favorite actors, Michael K. Williams, who played Omar in “The Wire.” The other was a triple fatal where the victims were believed to have used cocaine contaminated with fentanyl.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://www.npr.org/2021/09/06/1034655290/michael-williams-omar-the-wire-hbo-dies-at-age-54" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Actor Michael K. Williams, Who Played Omar on ‘The Wire,’ Has Died At Age 54</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://abc7.com/fuquan-johnson-overdose-venice-lapd/11001966/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Comedian Fuquan Johnson among 3 dead after suspected drug overdose in Venice</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">The New York Times recently ran an article <a href="https://www.nytimes.com/2021/08/31/nyregion/fentanyl-cocaine.html" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">“The Cocaine Was Laced With Fentanyl. Now Six Are Dead From Overdoses,</a>” which attributed a recent string of deaths to dealers deliberately lacing cocaine with fentanyl. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"> I believe they got it wrong. From all the people I have talked to and most of what I have read, these cocaine deaths are more likely caused by cross contamination than deliberate lacing. Many dealers, at least here in Connecticut, sell both fentanyl and cocaine. If they fail to properly clean their equipment (grinders, sifters, scales, etc.), just the smallest trace of fentanyl can get into the cocaine and cause someone naïve to opioids to overdose and die if they are using alone or if there are using with a friend who is unable to give them naloxone or call 911 in time.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I have a friend, who the circumstances of his homelessness led him to a part-time job bagging drugs for a local dealer. He packages both cocaine and fentanyl. I asked him how likely was cross contamination to occur. “Never,” he said, “We are very careful. We keep both drugs separate. Just the other night, I noticed my co-worker accidently put cocaine in the tray we reserve for fentanyl. I spotted it right away, and we set it aside as contaminated. We are very careful. You can’t be killing customers with contaminated cocaine. That’ll ruin your dealer’s reputation quick. Of course, not all baggers are as careful as we are.”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Enough said.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">If we really want to stop the deaths, we have to admit that people are dying from an unsafe supply, particularly from poorly mixed fentanyl. Fentanyl tends to clump (my friend attests to this). No matter how many times they put the mix through a sifter, the end result can still be a hot spot that can make a single $3 bag as lethal as a bullet to the head.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Packaging houses are not FDA approved. They are do not have quality safety standards.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Talk all you want about getting rid of fentanyl, it is not going to happen. We have never been able to get drugs off our streets. There are more and far worse drugs on the streets today than when the War on Drugs began back in the 1970s. Prohibition doesn’t work. Instead of following the same failed policies, if we are serious about lessening the deaths and ending the slaughter of far too many Americans, we need a new approach.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I am all for harm reduction, but it can only do so much.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I now believe we need to decriminalize drugs and replace our dangerous unregulated street supply with safe regulated drugs. We do this with alcohol, we do it in many states with marijuana. We do it with methadone and suboxone. We should do it with other opioids. In Canada, they have been successful with a pilot program that treats opioid addiction with dilaudid. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127701/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;"><span style="font-family: inherit;">Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction</span></a></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">We need to try approaches that work.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Stop the deaths. Replace what’s killing people with a safe, regulated drug supply.</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-18506986630437204052021-09-05T21:06:00.001-04:002021-10-31T21:08:01.311-04:00Paramedics Indicted<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-qeJFDOrvXH4/YX894-H4jQI/AAAAAAAAHA4/kPOGmPomKF484T2ApxYn2KHLlfUxSKF2wCLcBGAsYHQ/s1525/city.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1144" data-original-width="1525" height="240" src="https://1.bp.blogspot.com/-qeJFDOrvXH4/YX894-H4jQI/AAAAAAAAHA4/kPOGmPomKF484T2ApxYn2KHLlfUxSKF2wCLcBGAsYHQ/s320/city.png" width="320" /></a></div><br /><span style="font-family: inherit;"><br /></span><p></p><p><span style="font-family: inherit;"> <span style="background-color: white; font-size: 16px;">I have been a street paramedic since 1995. Up until 2008 I often worked 70 hours a week. That’s when I got a part-time job as an EMS Coordinator at a local hospital. In that position, I do quality assurance on the paramedic services that we oversee. I stayed full time as a medic, working Sunday through Tuesday 12 hour shifts, and then sat at the desk Wednesday to Friday. Two years ago, they bumped up my hours at the hospital, and for a while I worked 20 hours on the ambulance, but now I am down to Fridays in the city fly car, responding to 911 calls all day.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I like doing both jobs. Working in the street keeps me honest. On Monday I read another paramedic’s run form and wonder what he was thinking. On Friday, I find myself in the same situation and better understand what that medic was thinking. I am always reminded, it is never straight forward.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When I heard of the case of Elijah McClain (the young man who was by many accounts was assailed by police officers simply for acting strangely, and then medicated by paramedics with Ketamine, and shortly after went into cardiac arrest and died), I wondered about what actually happened. Since I was reading about the case for the first time on a Monday, I had my EMS Coordinator hat on. I read that the boy was given a Ketamine dose of 500 mg while he only weighed 143 pounds. The dose for Ketamine in Minnesota was 5 mg/kilogram (kg), while in Connecticut, for those services who carry it, it is 4 mg/kg. Elijah McClain received the dose for a 220 pound man. How did that happen? Paramedic math, I guessed. I see it often. 5 X 100 is 500 which is how much is in the vial. When it comes to pain management, I see the same thing with Fentanyl. 1 X 100 is the math for Fentanyl with its dose of 1 mg/kg and comes in a 100 mg vial. Reading the run forms, many patients it seems weigh 100 kgs. Ballpark the weight. 100 kgs. Yeah, that’s it. Give him the full vial. No need for math than than. Possibly lazy medics, I thought. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Then I get out on the street and I am reminded of the other side. It’s not that easy to accurately guess someone’s weight. Sure there are cases where you can ask the patient, but as any medic will tell you, people aren’t always honest about their weights and often are not in condition to have a reasonable conversation. I have calculated a person’s weight in the middle of a scene and then later seen the person stripped of all their clothes in the ED bed looking quite smaller. Same with ages. I did a bad car accident once where I thought the patient was in their early twenties only to later find out he was was twelve. Why wasn’t I at the pediatric hospital! And I did the opposite, transporting a traumatic arrest, thinking the patient was 12 only to find out she was in her twenties. Sometimes we work in chaos.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Recently I had to sedate someone who was running in circles, doing gymnastic somersaults on the hard pavement, slamming himself to the ground, then getting up and doing it again. He was sweating heavily, talking in voices, and then fighting when we tried to get him onto the stretcher. I use Versed as my sedation agent because the service I work for doesn’t yet carry ketamine (It’s on the way I’m told). Our Versed dose is 5 mg for adults, wait and then give another 5 mgs if necessary 5 minutes later. No need for math. We used to be able to give 10 mgs right off the back. I don’t like the 5 and wait 5 minutes. Waiting may look good in a protocol meeting, but when the patient is beating the crap out of everyone, it seems unreasonable. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">This guy was on the smaller side as opposed to some of the patients of linebacker size with prison muscles we get on PCP. I gave him 5 mgs. He was still fighting when we put him in the back of the ambulance. The crew wanted to tie him down and the cops wanted to accompany us. No, he’ll be asleep in a few minutes, I said. Let’s just keep him calm. I like to turn off the lights and say nothing and just passively push back their blows. I was already thinking I was going to give him another 5, but this guy was asleep within seconds of my statement. A minute later I was bagging him to support his declining respirations and get his carbon dioxide down to a reasonable level. I bagged him all the way to the hospital, where he ended up getting intubated and going to the ICU. (He ended up just fine, thankfully though I never found out what drugs he had on board beyond my suspicion of cocaine). The point I am getting at is you can sedate 10 people; each will react individually. It’s not like baking a cake. In EMS, the same recipe can have different results.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I don’t know what happened to Elijah McLain. What did the medics see when they arrived? Did they do easy math and give him a dose that turned out to be lethal for him? Or did Elijah die because of something the officers did? Or was it a combination of many other different elements? I do think it is hard for prosecutors to hold paramedics criminally liable for a death unless they have worked street calls themselves and better understand the conditions and variables, the variables of a call. And most importantly, they have evidence of malignant intent or gross negligence. I’d like to see these medics have a jury of their peers.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I don’t have the information to convict or exonerate them. And I don’t disagree with prosecutors that Ketamine (and other drugs we carry) can be considered a deadly weapon. Our EMS drugs can be deadly if not used carefully and with proper medical justification.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I will watch the trial closely and hope that justice is served. </span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">As an EMS coordinator, I will work to have the best, safest protocols for our medics to work under, and when questionable cases are brought to me, I will try to see them through the medics’ eyes, based on my own experience.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">As a medic on the street, I will continue to try to do what I believe is best for my patients, while working within the scope of our medical protocols/guidelines.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">No one ever said being a medic was easy. Do the best you can. Know your protocols. Use sedation with caution. Act on your patient’s behalf.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">And if you are ever indicted or called before your EMS Coordinator/QA person, tell the truth, help them understand what you saw and why you did what you did.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"><a href="http://officers%2C%20medics%20indicted%20in%202019%20death%20of%20elijah%20mcclain/" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">https://a</a><a data-id="https://abcnews.go.com/US/wireStory/elijah-mcclain-investigation-announcement-expected-79767107" data-type="URL" href="https://abcnews.go.com/US/wireStory/elijah-mcclain-investigation-announcement-expected-79767107" style="box-sizing: inherit; color: black; transition: all 0.1s linear 0s;">bcnews.go.com/US/wireStory/elijah-mcclain-investigation-announcement-expected-79767107</a></span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-20354893676521009452021-08-31T21:08:00.001-04:002021-10-31T21:26:15.050-04:00Overdose Awareness Day<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-TW_TNCiOkpM/YX9CKI9UeZI/AAAAAAAAHBA/6LFfeL-4qHMLjGZzkUzqSXtgBQ1UBmVLACLcBGAsYHQ/s1536/cross.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1536" data-original-width="1152" height="320" src="https://1.bp.blogspot.com/-TW_TNCiOkpM/YX9CKI9UeZI/AAAAAAAAHBA/6LFfeL-4qHMLjGZzkUzqSXtgBQ1UBmVLACLcBGAsYHQ/s320/cross.jpg" width="240" /></a></div><br /><p><br /></p><p> <span style="background-color: white; font-size: 16px;"><span style="font-family: inherit;">800,000 Americans dead since 2000. No end in sight.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">People are dying because they use alone and their drug supply is contaminated. In the age of fentanyl, every bag or counterfeit pill bought on the street could contain a lethal dose.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Stopping fentanyl at the border isn’t going to work.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">The War on Drugs (Interdiction and Prohibition) has been a failure. Community naloxone only goes so far. To significantly decrease the deaths, we need safe injection sites, decriminalization and creation of a legal safe drug supply.</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-67734598365664318352021-08-28T21:26:00.001-04:002021-10-31T21:28:07.466-04:00Conditions of Employment<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-sTgi8JvNIQQ/YX9Ch9afaFI/AAAAAAAAHBI/g-xnRGEMeoApHKLDzXBm_VsYs5VlcarfgCLcBGAsYHQ/s850/viral.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="611" data-original-width="850" height="230" src="https://1.bp.blogspot.com/-sTgi8JvNIQQ/YX9Ch9afaFI/AAAAAAAAHBI/g-xnRGEMeoApHKLDzXBm_VsYs5VlcarfgCLcBGAsYHQ/s320/viral.jpg" width="320" /></a></div><br /><span style="font-family: inherit;"><br /></span><p></p><p><span style="font-family: inherit;"> <span style="background-color: white; font-size: 16px;">Many years ago, a paramedic I know who worked for another company got into a spat with a nurse at a dialysis center. I don’t know the details of the spat. It sounded like nothing more than two people in a bad mood snapping at each other. Nothing that occurred resulted in a suspension or discipline for the medic or the nurse. The paramedic, however, based upon the nurse’s complaint to her supervisor, was barred from the dialysis center by the center. The center told the ambulance company he cannot enter our premises. To my knowledge he had no hearing, no chance to present a case. He was simply banned by a private business from entering their facility. What did this lead to? His apparently apologetic bosses had to fired him from his job. Not for poor performance or for anything he did or said that day. he was fired simply because as a condition of his job, he would at some point in the future, be required to enter that center either on a transfer or an emergency call, and his banishment from that center was a problem.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Again, I don’t know all the details, so we can call this a hypothetical case as opposed to a real case. Real or hypothetical, I thought it was incredibly unfair to the medic, who eventually left the state to work elsewhere. His employment was subject to the complaint of someone who might simply have not liked him. Maybe he could have hired a lawyer and battled it, but few in EMS have the money or stomach for that kind of fight. Some might just say, they are already on the verge of saying I have had enough, this just tips them over the edge. I’m out of here.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">The relevance of the story to today is this — private facilities are now beginning to mandate that only people who are vaccinated are able to enter their doors. Not just their staffs have to be vaccinated, but people entering their building to deliver or pick up patients must also be vaccinated. Some EMS agencies are also mandating their staffs be vaccinated.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I am actually for this. I see a difference between the two cases. In the first, the medic, at least in my opinion, is not a threat to the people he will be caring for in the dialysis center. A vaccinated provider, according to the best information I have read, while capable of passing COVID to someone else, is much less likely to do so than someone who is unvaccinated. If my mother were in a skilled nursing facility, I would want not only the staff caring for her, but also the EMTs and paramedics who may have to transfer her in the small contained unit of an ambulance, to be vaccinated.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">In our area, the hospital I work for has mandated staff be vaccinated. The ambulance service I work for hasn’t done this yet, but they have requested everyone’s vaccination status. I have also heard that a venue that we service will be requiring those who work there, including our paramedics and EMTs, to be vaccinated. I don’t know if this will include those sent in an ambulance for a 911 call, but it will certainly include those paramedics and EMTs doing standbys.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">It’s a crazy world. I find it hard sometimes to talk with others, and not feel frustration with their arguments. I have sympathy for the way they feel, but I am amazed at how each individual casts such different weight on the information that is out there. It is as if there are two different sets of facts. Certainly the politics of recent years has had some effect on this. I know some have speculated that if Republicans were hardline pro-vaccine and Democrats were saying vaccines should be a choice for individual liberty, many would hold opposite views to what they hold today with the same vehemence.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Recently I was reading an old post I wrote about vaccines in 2009, called Flu Shot, that attests to the fact that vaccine mandates have always been controversial.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">For me, in the choice between public health and individual liberty, I land on the public health side. I believe it is the right for private businesses to make that choice themselves. I would agree that governments should be able to make that choice too, but it should always come after careful, thoughtful review of the best available scientific evidence, and include necessary oversight.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Our government limits many things we do in the interests of the greater good. We wear seatbelts, we pay taxes, we can’t smoke in certain places, there are restrictions on pollution, etc., certain drugs are illegal. I may take issue with some of those when the potential harm done is only to the individual. I give the government more latitude when it prevents the harm being done to others.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I hope as a country, nation and a people that we can survive not only the brutality of COVID, but the deep divisions COVID and recent political battles have laid bare.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Peace to all.</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-78659367247277014092021-08-22T21:28:00.001-04:002021-10-31T21:30:56.247-04:00Apparition<p><span style="font-family: inherit;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: inherit;"><a href="https://1.bp.blogspot.com/-BJ_MDrzUfoY/YX9DPJNqpUI/AAAAAAAAHBQ/jr38V5ilKfosf7IlV5VzTQ4zVndGSgHIACLcBGAsYHQ/s1133/appa.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1133" data-original-width="850" height="320" src="https://1.bp.blogspot.com/-BJ_MDrzUfoY/YX9DPJNqpUI/AAAAAAAAHBQ/jr38V5ilKfosf7IlV5VzTQ4zVndGSgHIACLcBGAsYHQ/s320/appa.jpg" width="240" /></a></span></div><span style="font-family: inherit;"><br /><span style="background-color: white; font-size: 16px;"><br /></span></span><p></p><p><span style="font-family: inherit;"><span style="background-color: white; font-size: 16px;">Tim was working for the company when I started. As tall as me and twice as broad, he was a strong EMT — a good lifter, quiet sense of humor, hard worker, gentle with patients. And if he was standing behind you, no one would think of causing trouble. One night fifteen years ago, he came in off-duty and turned his uniforms in. Laid them on the supervisor’s desk. Said he’d had enough. He left without another word. That was the last I saw of him.</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Coming into work on Friday, walking into the cavernous ambulance garage that looks the same as it has for the last twenty-five years (except for different people checking out the ambulances or changing oxygen tanks) I didn’t need to close my eyes to see him. He was still there, walking with a limp from all the back pain, all the patients carried in the days when we did two man dead-lifts, walking away from the life that night, walking out into the darkness.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“What are you looking at?” an EMT friend said to me when she saw me standing there.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"> “Just thinking about the past,” I said.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Tim passed away on August 4 at age 64.</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-66099064974716893012021-08-15T21:31:00.001-04:002021-10-31T21:32:19.766-04:00Street Lessons<p> <span style="background-color: white; font-family: lato, lato, "helvetica neue", helvetica, arial, sans-serif; font-size: 16px;"> </span><span style="background-color: white; font-size: 16px;"><span style="font-family: inherit;">In 2012, I wrote a series called Street Lessons, but I could just as well call it any of the following:</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Things They Didn’t Teach Me in Paramedic School</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Things They Might have Taught Me in Paramedic School, but I Was on a Bathroom Break.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Oh Shit!</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Things I Learned The Hard Way</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Trial and Error</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Eureka! or Light Bulb Moments</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">***<br style="box-sizing: inherit;" /><span style="box-sizing: inherit; font-weight: 700;"><br style="box-sizing: inherit;" />Street Lesson # 1</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Don’t Carry Hypotensive Patients in a Stair Chair</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Over the years, I have had five patients go into cardiac arrest while I carried them in a stair chair. What does that tell me? It could mean that I carry a lot of patients in stair chairs. It could mean there are not very many elevators in the city I work in. It could mean I have done a ton of calls in my twenty plus years in the field. All would be true. And I can say I have never had an ambulatory patient go into cardiac arrest on me — at least not while I have been ambulating them. My first words to my partner on arriving at patient bedside are usually, “Get the stair chair.” The old saying “ABCs – Ambulate Before Carry” – it is not in my book of sayings.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Still five patients coding on the stair chair seems like a lot — certainly enough for me to wonder whether their coding was in any way related to their being on the stair chair.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">So why might they code on a stair chair?</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">They are sick and dying and called 911, and if we hadn’t arrived as soon as we did, they would have gone into cardiac arrest at that precise moment anyway.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">They are sick and dying and the fact that they were being carried down steep creaky stairs scared the last bit of life out of them.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Or maybe they were hypotensive and when we sat them up, their weak hearts couldn’t compensate, and that little extra bit of stress was enough to push them into the void.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I cannot remember the details of all five cases. But I can remember each of them dropping their head back or dropping it forward in a manner that indicated they no longer had muscle control. Sometimes they took a last gasp or two, sometimes not. I am a big believer in working a cardiac arrest right where they code, not losing a precious second in poor or absent CPR. Still it is hard to just stop carrying someone mid-stair case and start rescusitation.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“You know what just happened?” I will say to my partner.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“What?</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">“The patient just coded.”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">So what is the lesson in all of this (Besides, expect if you do enough calls and carry enough people some will code on the stair chair)?</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">My lesson is — if the patient is hypotensive while supine or borderline hypotensive and they are sick, consider carrying them in a scoop stretcher.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">A 20-year-old with a pressure of 80 due to vomiting may be less at risk that an 80-year-old cancer patient with altered mental status, tachycardia and a pressure of 100. If a patient gets dizzy sitting up, then don’t use the stair chair. It may not spare you having them arrest on you during extrication, but it will be less likely to cause harm.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Street Lessons #2 Troubleshooting the Monitor</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">In paramedic school, you are taught to apply your cardiac monitor to patients having chest pain as well as a variety of other aliments. Simple enough. If your teacher hasn’t told you, then your preceptor should be grilling it into you to always bring your monitor in to each call, as well as your house bag. Some might say you should also be bringing in your suction –anything you might need. You never know what you are walking into. But in this post we are going to just talk about the cardiac monitor, and we are going to assume you have it with you. (At least in cases A-D). Here’s where the problems begin.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Problem A </span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Both batteries are dead. You checked them this morning and you swear they both had four bars. Now the monitor is either completely dead or the batteries are both down to one and flashing that they need to be changed, and then they go dead. What happened? Well, you thought you turned the monitor off after you checked it at the start of your shift, but you didn’t, and all this time the machine has been sucking the batteries down. I can tell you I have on several occasions been driving to a cardiac arrest and just before I arrived, heard a sudden beeping from the back and the voice saying “Change monitor batteries.” What do you do? If you are still in the truck when the battery is beeping, you change the batteries out. Simple enough. But let’s say they are both dead and you don’t notice until you are in the house. You take the spare battery out of the back. How do you know you have a spare battery? Because this has happened to you before, so you always keep a spare battery in the back now. Always.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Problem B</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">The batteries are good, but when you attach the electrodes, nothing reads on the screen. You recheck the leads and connection to the monitor, which you unplug and then replug several times, all with no change. Still nothing. You take the electrodes off and apply some new ones from the same open bag, and still nothing. You blame the monitor. Is it the monitor? No, some of you may have guessed from your experience or from what I have written that reveals the clue. The problem is the electrodes are from an open bag and they are dried out. You were smart enough to switch electrodes, but you took the new ones out of the same open bag. Try to always get your electrodes from a fresh pack, or at least keep a spare fresh pack in case you have this problem. I know some medics like to preattach their electrodes, which is okay if you are very busy, but know this — from the moment you take them out of the bag, they start to dry out, and the drier they are, the worse the ECG quality will be until you get nothing at all.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Problem C</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">You need to do a 12-Lead. Whoops, you have the regular cable, but the 12-lead attachment cable is missing. It fell out and no one noticed or you forgot to check carefully this morning. Either way, all you have is the four leads and your patient is having crushing pain and is cool, clammy and diaphoretic. What do you do? A modified 9-Lead. This is how we did 12-leads before we had Life-Pack 12s. Take the left leg lead — the red lead, and move it to the V1 position. Run Lead III in diagnostic mode. Repeat with V2, V3, V4, V5 and V6. Label each lead as follows: McL (modified chest Lead)1, McL2, McL3, etc… While not exact replicas, they do passably well. You do this and see hyperacute T waves in McL3 and McL4 and McL5. Call in a STEMI Alert.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Problem D</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">This time you have your 12-Lead cables, but that is all you have. You don’t have the four lead cables and without those, you can’t attach the 12-Lead cables. Your patient is alert, but very clammy and you can’t feel a pulse. What do you do? Take out the defib pads, and apply them to the chest. Hit paddles on the monitor and while you won’t be able to get a 12-lead, at least you know the rythmn and if it happens to be VT, you are all set. If if is an SVT, and you want to give adenosine, go ahead, just be certain to hit print. If it is a sinus, well at least you know that.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Problem E</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Okay, so this time you are dispatched to a chest pain call and when you go to grab your monitor, there is no monitor. D’oh! What happened? Who knows, but we could assume what happened to you is what happened to me as chronicled in the post D’oh! I was lucky enough that my call was not a chest pain, but a BLS call. Had it been a chest pain, I would have had no choice but to fall back on my BLS skills and call for a paramedic intercept. Even if I was revealing my lapse and subjecting myself to punishment, you can’t let the patient be harmed. Go ahead and call for a medic, and hope that your company and or medical control is lenient with you.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;"> Street Lessons #3 Know Thy Patient</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Ahh, the simplest things. You need the patient’s name, date of birth, and social security number if possible. The name is most important. If the name is John Smith or Juan Martinez, the date of birth helps.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I was a brand new spanking EMT and we had a patient in classic CHF — I am talking hypertensive through the roof, bulging jugular veins, filling emesis basins with pinky frothy sputum. We had him on a nonrebreather, on a stair chair, out to the ambulance, and lights and sirens half way to the hospital before we realized we didn’t who he was, and he was still working at breathing too hard to get a syllable out. No name, no DOB, no social, just the address we picked him up at. Chalk that one up to two excited rookies.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">On most calls, if you leave the house without the patient’s name, this is no problem, the patient can tell you. In the past, I didn’t often bother with this information if the patient was talking to me. I figured I could get it out in the ambulance. I look at the elderly patient and say “You know your date of birth and social security number?” The patient looks me right in the eye and says “yes, sir.” Very good.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">On the way to the hospital, after I have done an IV and 12-lead, I ask the patient for his date of birth. “Yes, sir!” he says. Same answer to social security number. I ask him his name. “Yes, sir!”</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Always get the name and social.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I am in the nursing home and the nurse hands me the envelope. I take a quick look at it to see if there is a name, date of birth and social security number filled in on the paperwork and that I can read it. Check. Check. The patient is unresponsive. Out in the ambulance, I am checking the patient’s meds to see if they provide a clue to their condition. I notice then that patient’s name is Mary Wilson. The problem is the patient is a man. I send the paperwork back into the SNF with my partner who comes out with an apology and the paperwork for Richard Johnson.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Here’s one. Nursing home patient is unresponsive. Ambulance crew takes patient and paperwork. Patient’s blood sugar turns out to be 29, but he is not a diabetic. They give him D50, and he comes around, but is still somewhat confused. At the hospital they keep him overnight to do tests and figure out why he dumped his sugar considering he is not a diabetic. Plus he is still confused. He won’t answer to his name. Later that night, the hospital gets a call from the nursing home to check on the patient. Who? The hospital says, we have no one by that name here. Later the hospital calls the nursing home back. We do have someone here from your facility named Edward Thomas. Ahh, no you don’t. Edward is right here next to me in his wheelchair. Whoops. No wonder the man in the hospital bed won’t answer to his name. Turns out the patient is a diabetic after all.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">You have to check the name. If the patient can’t confirm it, check for a name bracelet. No bracelet? Get a nurse to verify the patient and paperwork are one and the same.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">You’d think it would be easy, but it’s not. The times I’ve been on calls and had a first responder hand me a piece of paper with the patient’s name and information on it, and its been the first responder’s previous patient, and not this current one. The times it has been the right patient and I have put the paper in my right pocket, but then pulled a piece of paper out of my left pocket and started typing in the name on the left pocket piece of paper. Not the patient in front of me.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I try hard now. I introduce myself to the patient and get the patient’s name or get someone to tell me the patient’s name. Mistaken identity can lead to serious errors, and those we always want to avoid.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Street Lessons #4 Carry Your Gear</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Always carry your gear into calls. I know it can be a pain to do, but nothing is worse than suddenly needing your equipment and not having it.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">A woman calls 911 and says “my baby is sick!” You get dispatched for a sick baby. You think if it is a sick baby, what do you need equipment for? Most likely the baby is not really sick, but if the baby is really sick then you can, as my preceptor once said to me, “O.J. it.” This of course was when O.J. Simpson was known for running and leaping faster than any other human and not known for slashing throats. “O.J it” meant grab the baby and run for the ambulance.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Many times in my early years as a medic I “OJed” it with sick kids, sometimes doing CPR and tiny breaths as I went, hurtling toward the ambulance, my office where the gear that made me a medic was stowed. Aside from that clearly not being the ultimate way to resucitate a baby or anyone for that matter, the “sick baby” call doesn’t always turn out to be a sick baby. The sick baby can be anything from a 300-pound fifty-two-year old son in cardiac arrest to a vomiting parrot. The 300-pound son you clearly wish you had your gear for. The vomiting parrot? Well, that’s another story.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">When I started there was one paramedic who always carried all his equipment in on every call. Back then we had a black hard suitcase called a biotech for the meds and IV supplies. We had an intubation kit, we had a large house bag with the oxygen and bandaging supplies, and we had the Life Pack 5 and then the Life Pack 10 monitor. We also had an orange tackle pedi-box.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Now this medic didn’t bring the pedi-box in on every call unless it sounded like it might be a pedi. For the sick baby that turned out to be the 300-pound fifty-two-year-old son, he would have had the pedi box there along with everything else where other medics would have had to send their partners running back down to the truck.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">He also– and this is what impressed me the most — he always carried the portable battery-operated suction machine in. Every call. Me, I only bring it in to a known cardiac arrest, and I can tell you to my embarrassment, two of the last three difficulty breathings I’ve been too have turned out to be cardiac arrests where my preceptee has said, “I need suction!” when he has put the larengyscope in and seen nothing but murky waters. “I need suction now!” On its way. but not here yet.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">We had a paramedic here who was fired for not bringing equipment in. She sometimes brought equipment in. Say it was a known cardiac arrest, she would put a larengyscope, a tube and a 10 cc syringe in her pocket. I kid you not. She also downgraded a stabbing because the hole in the chest was “just a little hole.” Lazy paramedic. Bad paramedic.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I carry in the house bag and the monitor, and the 02 if the fire department hasn’t gotten there yet, although there have been times when I have climbed up three flights of stairs only to find the fire department also didn’t bring in their 02. I hate not being prepared.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I carry my controlled substances on me when I go into a call. While there is some lack of clarity as to what exactly the rules are in our state governing the securing of controlled substances — it ranges from they must always be secured doubled locked in the ambulance unless you have the intention to use them to its okay to secure them on yourself as long as you are on the clock and capable of being dispatched to a call where you might need them. The issue here is: what if you respond for a person vomiting and after wheeling your stretcher down many halls and up a couple different banks of elevators in a big insurance company, you find your patient is actually seizing? You can either 1) Put the patient on your stretcher and wheel them seizing all the way back out to the ambulance. 2) Give the controlled substances keys to your BLS partner and tell him to get the kit and hurry. 3) Or you can take the controlled substances kit out of your own pocket and stop the seizure now. I hate being without my gear when I need it.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched — the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, “he’s up on the 2nd floor.” We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with gurgling respirations and an ever growing pool of blood around his head. “He got the shit kicked out of him,” the cop says — “steel toed boots.” “Uh-o,” Steve says to me. “Go get the gear,” I say to Steve.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">We work together the next week. No “uh-o” moments we both agree. We’ll bring the gear in on every call. First call of the night is for a “woman drunk wants to go to rehab.” This is a call we do all the time too. We walk in, meet the patient, who says, “I want to go to rehab.” And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door — also up on the second floor. “My daughter is an alcoholic,” he says. “She needs to get cleaned up. I don’t think she’s breathing.” Uh-o. Go get the gear.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I know the gear is heavy, but look at it this way, you are in physical training. Carrying all that gear up and down stairs will get keep you in shape and keep you young. Do enough calls, walk up and down enough staircases and you can skip the gym after work and spend the time with your family.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Street Lessons #5 The Hand Drop Test</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Anyone new to EMS is likely as amazed as I was at how many patients feign unresponsiveness. We all likely have had a moment when a more experienced responder has demonstrated the “Hand Drop Test,” where they raise the patient’s hand over their face and release it. If the hand smacks the face, they pass the test and truly are unresponsive. If the hand stops or is moved to the side to avoid contact, then the patient fails the test and is a FAKER. Or so it goes. The best FAKERS, I was told, know our tricks and so let their hands smack their faces because they are wise to what we were trying to prove. I was told to look out for these master fakers.*</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">There is a second more valuable lesson than the Hand Drop Test, a lesson that comes later and often comes painfully to your own performance as a paramedic. And that lesson is just because a person is aware enough to move their hand to avoid their face, doesn’t mean they can’t also be really sick.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">What do you mean? They have an intracranial bleed? They failed the hand drop test!</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">What do you mean? They are in acute renal failure? They failed the hand drop test!</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I was burned by this early in my career, but never again.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">All a person needs to fail the hand drop test is a smidgeon of consciousness, and a quarter ounce of remaining strength. It merely tests for a smidgeon of consciousness and a quarter ounce of strength. It does not provide proof that a patient is not sick or injured.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Also, if the results of all your other assessment capabilities still leave you wondering, and you just have to do the hand drop test, make certain that you protect the patient. A paramedic caused bloody nose should not be considered collateral damage from having to do the hand drop test.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">* I no longer feel it is my job to unmask fakers. If I suspect someone is faking, I find it easier to just pick them up, put them on the stretcher and take them out to the ambulance, than to try to prove to the surrounding crowd that the patient is conning everyone.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="box-sizing: inherit; font-weight: 700;"><span style="font-family: inherit;">Street Lessons # 6 Don’t Always Believe Your Own Eyes</span></span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;"> When I was a new EMT, I responded to a call for an unconscious person. In the basement of a house, I found a woman in her thirties unconscious of the floor and her husband shouting frantically that his wife was dying and that he had in fact done CPR on her for several minutes. “Help her,” he demanded. “I am,” I said. I was kneeling beside her and feeling her pulse, and watching her breathe. While she was in fact unconscious, her breathing was even and her pulse was steady. Her skin was warm and dry and she didn’t have a scratch on her.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">My partners had told me stories of people doing CPR on living patients and always laughed at them, and while in my career I would encounter this phenomenon again and again, this was first time seeing it, and I thought, I am an EMT, the person is breathing and has a good pulse. This man is just a layperson who is very panicky and I think it is a good bet she did not actually need CPR when he was pounding on her chest. Perhaps she is on drugs. Her husband denied that when I asked. To this day, I am surprised he did not beat me for suggesting it. I guess he was clinging to the belief that maybe I could help her.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Well, we got her on the stretcher and out to the ambulance, and wouldn’t you know, ten minutes later, she stopped breathing and we were doing CPR.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">A wise person told me once when I arrived on scene to always acknowledge the first responders or the bystander if there were no responders and get a report. Some reports would be excellent, some would be crazy. The point the wise man made was to simply show respect. “I did CPR on her for a couple minutes and then she came around,” the woman would say. “Great,” I would respond. And then get on with managing the syncopal victim with the now bruised sternum.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">But let me tell you this now. I would add a caveat to the acknowledge the first responder advice, and that caveat would be “Listen to them.” I know sometimes in the past, while pretending to give my full attention, my mind has been going yadeedaa.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Now I say this because in my career, while I have had first responders or bystanders describe what seemed like crazy things compared to what my eyes were seeing when I arrived. I have had those same seemingly okay patients suddenly revert back to what the bystander or first responder described. “Sure, you were doing CPR, great Job!” I’d say, thinking that’s a laugh, only to find myself doing compressions five minutes down the road. Or to have the responder describe the crazy seizure they witnessed, only to have the patient startle me with the same earth-shaking tonic-clonic seizure later on down the road.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Don’t assume because the person is fine now, that they were fine when 911 was dialed.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">I am not saying to take everything a first responder or lay person says as gospel, only to consider it. Never dismiss any information outright. If someone says the little girl with the polka dot dress’s head spun around three times and fire came out of her mouth, I will store that nugget in a small, but retrievable place.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">In EMS the hierarchy on a call goes something like this. Bystander, first responder, EMT, paramedic, with each higher level of care assuming command as they arrive. The hierarchy continues at the hospital. Nurse, Doctor. Although some of us paramedics would argue the nurse is not above us, most hospitals are structured where the paramedic turns the care over to the nurse, who makes the decision where the patient goes next – a regular room or a critical care room.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Has it ever happened to you where you have described the extremely sick patient you encountered who now seems fine, and had the triage nurse or the doctor be somewhat dismissive of your account because of what their own eyes are telling them? I am sure it has if you have worked any amount of time.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Doctor, he was pale and diaphoretic. Nurse, she was in full seizure. Doctor, he was completely unresponsive. Nurse, he was blue. Doctor, I know it isn’t on yours, but I have ST elevation on my 12-lead.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Waiting room. Or a bed in the hallway.</span></p><p style="background-color: white; box-sizing: inherit; font-size: 16px; margin: 0px 0px 1.5em;"><span style="font-family: inherit;">Later, you hear: Hey your patient coded in the bathroom. Or they found your patient seizing by the coke machine. Or perhaps: Yeah, didn’t you hear? The hospital burned to the ground with only one survivor, a little girl in a polka dot dress standing in the midst of the rubble, unharmed</span></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-3966255861934629932021-08-10T15:10:00.001-04:002021-08-10T15:10:26.425-04:00Old Friend<p>We used to (25 years ago) pick Darryl up every night around 10:00 PM. He’d call from the pay phone on Barbour Street. He was drunk and cold and wanted a ride to the hospital where they would put him in the waiting room and he would fall asleep in one of the chairs. He could be combative with crews who gave him a hard time, castigating him for wasting precious 911 resources. Sometimes if he took a swing at an EMT, he ended up in jail for the night. I learned early on that it was easier to just pick him up and take him to the hospital than get all worked up about it. Daryl was just a part of the night in the same way the battle ax triage nurse was. You just dealt with him professionally and moved on. </p><p>I remember one night, he called an hour or so early. He wasn’t even drunk. He held a Styrofoam box of chicken wings and fries from the local chicken place. It was the night of the NCAA basketball championships and he was excited for the big game. He sat down in front of the TV next to a couple of buddies and rooted for his team while chowing down on his chicken and fries.</p><p>He’d be a regular for a few years, then disappear only to reappear again a few years later, back on Barber street, calling from the pay phone that isn’t there anymore. His disappearances coincided with stints in jail when his anger got the best of him or rehab if that’s what the judge ordered..</p><p>A few weeks ago, early on a Friday evening, I got called for an unconscious on Barber Street in front of the boarded up grocery store. The fire department was there before me as well as an ambulance crew with two new EMTs. The man was laying on the ground, clearly ETOH and telling everyone to F-off and leave him alone. One of the EMTs tried to grab his arm, as he said “Let’s go, buddy,” but the intoxicated man jerked his arm away, and then took a wild swing that missed by so much, you couldn’t even consider it an assault. I was looking at him like I knew him from somewhere when it came to me. “Is that Darryl?” “Yeah, one of the firefighters said. “He’s becoming a regular for us.”</p><p>I stepped forward and said, “Darryl, Darryl. Is that you?”</p><p>He stopped swearing at the EMT and looked up at me. There was a recognition in his eyes like he knew me from somewhere, but he couldn’t quite place me. “I know you,” he said. “Is that you?”</p><p>“It’s me,” I said.</p><p>“My my,” he said. “I know this man.” He held his hand up and I helped him up.</p><p>“Why look at you,” he said. He turned to everyone and said. “He and I went to rehab together!” Then to me, he said, “Look at you! Look at you now! Oh! You’ve done well for yourself. You’ve done well for yourself!”</p><p>He gave him a bear hug, and then looked at me again. “You’re looking great,” he said.</p><p>“You’re not so bad yourself,” I said. “You know why we’re here, right?</p><p>“Was I making trouble?”</p><p>“You just can’t sleep on the ground without expecting someone to call 911. We just see if you’re alright.”</p><p>“I’m all right. I’m glad to see you.”’</p><p>“You know where you are?”</p><p>“Barber Street.”</p><p>“Very good. If you are able to walk away. We’ll leave you alone.”</p><p>“All right. I’ll be walking.” Then he stopped and said. “Look at you. This here’s my friend,” he said. “We were in rehab together. He’s doing all right. We both all right.”</p><p>Whether 911 was called again later, I don’t know. He walked off under his own power, and I went home at the end of my shift, and told my wife the story.</p><p>If he did end up in the ER, I hope whoever took care of him, treated him okay, not getting riled by his rough manner, getting him some ginger ale and a sandwich and maybe letting him watch TV if a game was on, keeping him dry on what turned out to be a rainy night.</p><p><br /></p><p><br /></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-54439902559591456002021-08-08T15:01:00.004-04:002021-08-09T07:18:04.639-04:00Falsehood Flies<p> <span style="font-family: "Times New Roman", serif; font-size: 12pt;">“Falsehood flies, and truth
comes limping after it, so that when men come to be undeceived, it is too late;
the jest is over, and the tale hath had its effect.”- Jonathan Swift, <i>Gulliver's Travels</i></span></p><p style="text-align: center;">***</p><p class="MsoNormal">This week, the San Diego County Sherriff’s Department posted a <a href="https://www.sdsheriff.gov/#Top" target="_blank">video</a> purporting to be a deputy overdosing after minimal contact with fentanyl powder and requiring naloxone resuscitation. The story was picked up by newspapers all over the country, including the Los Angeles Times.</p><p class="MsoNormal"><a href="https://www.latimes.com/california/story/2021-08-06/im-not-going-to-let-you-die-deputy-overdoses-after-coming-in-contact-with-fentanyl" target="_blank">Authorities say San Diego County deputy overdosed after coming in contact with fentanyl</a><br /></p><p class="MsoNormal">For the average reader, this is pretty scary stuff. Now there is no doubt that fentanyl is responsive for hundreds of thousands of deaths. But those deaths occur when users deliberately inject fentanyl into their blood stream, inhale directly into the nose, or ingest fentanyl contaminated pills. People do this many times a day and rarely overdose. The overdose is usually caused by disproportionate mixture of fentanyl in the powder or pill. People are not dying merely from coming into close contact with fentanyl. </p><p class="MsoNormal">There was a rash of these stories that began back in 2016 when the DEA released a two-minute video, <a href="https://www.justice.gov/opioidawareness/video/fentanyl-real-threat-law-enforcement" target="_blank">Fentanyl: A Real Threat to Law Enforcement</a>. Jack Riley, the deputy administrator, opens the video by stating that “a very small amount (of fentanyl) ingested or absorbed through your skin can kill you.” He introduces two police detectives who describe their experience with a fentanyl exposure. One detective describes how, in sealing a baggie of the drug, some of it “poofed up” into the air, and the detectives ended up inhaling it. “I felt like my body was shutting down,” the other detective says. “People around me say I looked really white and lost color. And it just really felt like . . . I thought that was it. I thought I was dying. That’s what my body felt like. If I could imagine or describe a feeling where your body is completely shutting down, and, you know, preparing to stop, stop living, you know, that’s the feeling I felt.” The first detective adds, “You actually felt like you were dying. You couldn’t breathe, very disoriented. Everything you did was exaggerated in your mind, I guess. It was the most bizarre feeling that I never ever would want to feel again. And it was just a little bit of powder that just puffed up in the air.” Riley concludes, “Fentanyl can kill you.”</p><p class="MsoNormal">As I watched it, I thought about being a paramedic for more than twenty years. What they were describing didn’t sound like an opioid overdose. People who use heroin describe it as the most wonderful feeling they have ever experienced. They feel euphoria. The comedian Lenny Bruce described it as like kissing God. They give up everything they have to “chase the dragon.” What these detectives were describing didn’t sound like an opioid reaction; it sounded like anxiety.</p><p class="MsoNormal">The next year the DEA released <a href="https://www.nvfc.org/wp-content/uploads/2018/03/Fentanyl-Briefing-Guide-for-First-Responders.pdf" target="_blank">Fentanyl: A Briefing Guide for First Responders</a>. It includes the following passage:</p><p class="MsoNormal"><i>Personnel should look for any cyanosis (turning blue or bluish color) of victims, including the skin or lips, as this could be a sign of fentanyl overdose caused by respiratory arrest. Further, before proceeding, personnel should examine the scene for any loose powders (no matter how small), as well as nasal spray bottles, as these could be signs of fentanyl use.</i></p><p class="MsoNormal"><i>Opened mail and shipping materials located at the scene of an overdose with a return address from China could also indicate the presence of fentanyl, as China-based organizations may utilize conventional and/or commercial means to ship fentanyl and fentanyl-related substances to the United States. </i></p><p class="MsoNormal">I had to read the passage several times to make certain I understood it. I focused on one key phrase: “before proceeding” The DEA was saying that before treating a person with agonal respirations--someone moments from dying--emergency personnel should check the scene for packages from China.</p><p class="MsoNormal">I wrote in this <a href="http://www.medicscribe.com/2017/06/22/fentanyl-a-briefing-guide-for-first-responders/" target="_blank">blog</a>, <i>“If a patient is unresponsive and cyanotic, breathing two times a minute, unless they have fallen into a Scarface mountain of powder or any amount of powder that I think might compromise my ability to perform my duty of saving their life, I am going to put my gloves on, don my N-95 mask, grab my bag-valve-mask and start breathing for them. I am most certainly not going to wait to treat the patient until after I have scoured the cluttered room for hidden packages from China.”</i></p><p class="MsoNormal">The DEA’s warnings led to a rash of fake overdoses being reported as real, and one community in Massachusetts even spent $75,000 on a hazmat response where three people overdosed. </p><p class="MsoNormal">The LA Times, in a<a href="https://www.latimes.com/local/lanow/la-me-ln-drug-hazmat-santa-ana-20170726-story.html" target="_blank"> story about a drug overdose scene </a>in July of 2017, warned that “a small dose of the odorless white power can be fatal.” The story described the police response to an overdose call: “Officers have been trained to ‘back off’ when they come across white powder and an unconscious victim at the scene of a call.” It was unclear from the article how long treatment was delayed to the three overdose victims, one of whom died. My hope was that medics, with proper personal protective equipment (PPE), were allowed to go right in to treat the patients. Police corporal Bertagna is quoted as saying, “A woman and three children were also found in the 800-square-foot apartment and removed.” Bertagna continued: “They, along with the officers and paramedics, all underwent decontamination, essentially an intense shower.” The fact that a woman and three children were alert in the same apartment suggested that the scene was safe.</p><p class="MsoNormal"> On July 27, 2017, the American College of Medical Toxicology and the American Academy of Clinical Toxicology had to issue a joint statement, <a href="https://www.acmt.net/_Library/Positions/Fentanyl_PPE_Emergency_Responders_.pdf" target="_blank">Preventing Occupational Fentanyl and Fentanyl Analog Exposure to First Responders</a>, stating that “the risk of clinically significant exposure to emergency responders is extremely low.”</p><p class="MsoNormal">I nationally known toxicologist I spoke with suggested you would have to sit in a bathtub full of fentanyl for an extended period of time for it to have any effect on you. Transdermal fentanyl patches which are specially designed to provide medicine through the skin take hours to work.</p><p class="MsoNormal">I thought these stories had finally come to end and then the San Diego story surfaced. You would think the Los Angeles Times would call medical experts and ask their opinion and then report it with more weight than a Sherriff claiming his deputy had overdosed on fentanyl.</p><p class="MsoNormal">Imagine a story in a legitimate newspaper. Headline - BOY PURPORTEDLY ABDUCTED BY ALIENS, but the article has no scientific evidence of the abduction only quotes from board members of the UFO Society who say aliens are responsible for hundreds of thousands of childhood and pet disappearances. Buried in the article, a professor at MIT says, “the boy’s story is not plausible.” Then the article ends with the boy’s father saying, “My boy would have died if I hadn’t grabbed his foot and pulled him out of that space ship.” That’s about what happened with this story.</p><p class="MsoNormal">If you want to read more about this issue, read chapter 14, “Responder Safety” of my book <a href="https://www.amazon.com/Killing-Season-Paramedics-Dispatches-Epidemic/dp/1421439859/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=1628448827&sr=8-6" target="_blank">Killing Season: A Paramedic's Dispatches from the Front Lines of the Opioid Epidemic</a>, in which I discuss the issue of fentanyl safety.</p><p class="MsoNormal">The New York Times weighed in on the San Diego incident.</p><p class="MsoNormal"><a href="https://www.nytimes.com/2021/08/07/us/san-diego-police-overdose-fentanyl.html" target="_blank">Video of Officer’s Collapse After Handling Powder Draws Skepticism</a><br /></p><p class="MsoNormal">As of today, the Sherriff's office still has the video posted on their site despite demands that it be retracted -- a letter from a concerned group of health professionals, first responders, public health researchers, drug journalists, and people with lived experience. (I am one of the 170 people to sign it to date.)</p><div><br /></div><div><span style="font-family: Arial; font-size: 11pt; font-weight: 700; text-align: center; white-space: pre-wrap;"><br /></span></div><p class="MsoNormal"><a href="https://docs.google.com/document/d/1nDcfF5_OKr9r-U59YwDhWEk5a7GekYspkNVSy0DbkqQ/edit" target="_blank">Retraction Request</a><br /></p><div><br /></div>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-75200446291827051532021-04-06T08:33:00.001-04:002021-07-05T08:34:32.558-04:00Naloxone and Cardiac Arrest: new Scientific Paper from AHA<p> In 2010, the American Heart Association wrote “naloxone has no role in the management of cardiac arrest.” This came as a surprise to many medics who routinely gave naloxone to cardiac arrests patients suspected of opioid overdoses, and may come as a surprise to many medics who continue this practice.</p><p><br /></p><p>The idea against using naloxone is fairly simple. If the opioid overdose caused the cardiac arrest, the cause of death is hypoxia. Naloxone can reverse apnea in patients who are still alive, but naloxone cannot undo a hypoxic death. Patients in cardiac arrest from opioid overdoses need to get their hearts started with epinephrine, and they need to be ventilated. All naloxone can do is put the patient in withdrawal should they be resuscitated with ACLS drugs. What about ventilation? That’s what ambu-bags are for.</p><p><br /></p><p>In their new March 2021 paper, Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association, the AHA maintains this same position. They write: “naloxone does not have a likely benefit in patients with confirmed CA who are receiving standard resuscitation, including assisted ventilation, and there are some reasons to suspect that this practice may cause harm by increasing cerebral metabolic demand at a time of hypoxemia and acidosis.” They also write “If the patient is definitely pulseless and receiving standard resuscitation, including assisted ventilation, naloxone is unlikely to be beneficial. Because there is a theoretical basis for harm, standard resuscitation alone is indicated.”</p><p><br /></p><p>Where the 2021 protocols differ from the 2010 is the distinction for lay people and for medical responders who are unable to determine if a patient is truly pulseless. In these situations, the AHA says, and I agree, “Clearly, some patients present with respiratory arrest and faint or difficult-to-palpate pulses; these patients are likely to benefit from naloxone” and “Opioid antagonism… is always reasonable and should be delivered along with CPR when it is uncertain whether the patient is pulseless.”</p><p><br /></p><p>Bottom Line: Paramedics should not deliver naloxone to patients in cardiac arrest once they confirm with palpation and their monitor, a patient is in cardiac arrest. It will do no good, and may cause harm. Laypeople and BLS providers should deliver naloxone to patients whose pulses they cannot feel and who they have reason to believe might have pulses. The benefits here outweigh the harms.</p><p><br /></p><p>I am doing some research on this issue with Connecticut SWORD data base and can report that it is quite common for both lay people and first responders to do CPR and administer naloxone to patients, who are found to have pulses on paramedic arrival. Failure to deliver naloxone to these patients on the grounds they were in cardiac arrest would definitely have been harmful.</p><p><br /></p><p>I can also tell you as a street paramedic, I have found apneic and pulseless to my palpation patients who, on attachment to my monitor, were found in narrow complex tachycardias, and who responded well to an ambu-bag and naloxone.</p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-49729369890393248192021-04-03T18:04:00.007-04:002021-04-03T18:32:10.991-04:00Men With Guns<p><br /></p><p>I was a new paramedic. The senior medic briefed me. They took two guys out of a basement apartment with high carbon monoxide readings after a dryer caught on fire. Ones already on the way to the hospital for evaluation. Your patient is the guy over by the building door arguing with the police officer. He wants to go back in his apartment to get some items, and the officer won’t let him. Just then the man punched the officer in the jaw.. The officer threw the man against a car and put him in a headlock, and then handcuffed him. Instead of bringing him over to us to be evaluated, the officer put him into a squad car. “Asshole!” he shouted at the man.</p><p>“Do you think he’s an asshole or do you think maybe carbon monoxide is making him act like an asshole?” I said to the other medic. “Shouldn’t we go over there and talk to him?”</p><p>The medic shrugged, and said, “You can’t argue with a man with a gun.”</p><p>The cop took him to the police station for booking and we cleared the scene “Patient item A (arrested).”</p><p>Hours later we both happened to be in the hospital EMS room when a supervisor came in and told us the man had become increasingly altered at the police station and was rushed to the hospital where they found critically high carbon monoxide levels in his blood. “I’m glad it wasn’t my patient,” the senior medic said, without looking at me.. </p><p>I spent the week worrying that I was going to get a phone call telling me my medical control had been taken away and I was finished as a paramedic. Fortunately, that call never came.</p><p>That was over twenty-five years ago and I was still learning my way.. The episode taught me two lessons. Don’t rely on someone else to make the good decisions for you, and if you are there as a medic, you need to speak up on behalf of your patient, prisoner or not, asshole or not..</p><p>I am not saying that from that point on I always stood tall, but I was at least headed in the right direction.</p><p>Over my twenty-five plus years as a paramedic, I have had clashes with police officers regarding patient care, less so as the years have gone by and police departments have become progressive, and possibly I have learned a calm, assertive manner.</p><p>When I worked in a contract town, I was always getting called to evaluate prisoners for “jailitis.” There was pressure for me to tell the prisoners they were fine and did not need to go to the hospital. Sign here. If I insisted on them going to the hospital, the police department (PD) would have to send an officer along and the officer would have to wait as long as the prisoner was there, or until an officer from the next shift arrived to relieve him.</p><p>The PD wanted to cover their liability by calling me so they could say they offered the prisoner medical help when asked, but they wanted me to shoulder the responsibility for the refusal of transport. I played it straight forward. If I thought the person was sick, I advised them to go to the hospital. If I thought they weren’t sick, I’d tell them what I believed, but always made clear if the patient requested to go to the hospital after my evaluation, I would fight for their right to be evaluated there. It would be up to the PD to refuse.</p><p>I noticed sometimes the PD would wait till my shift was done and another (more pliant) medic was on to call for the prisoner evaluation.</p><p>I have also responded to scenes where the police were sitting on patients, and I have always done my best to make certain that the person being sat on could breathe and that if they were going to be restrained, it would be in the safest manner possible. I prefer 10 mg of Versed to four point restraints and a spit shield. I have said clearly, “This man needs to be evaluated at the hospital.”</p><p>The line the medic used that day-- “You can’t argue with a man with a gun”--I have heard many times over the years --medics explaining why they did not immediately treat a patient who needed care, or why an MVA victim was transported to jail instead of the hospital, only to later need an ambulance, or even a shooting victim was left to die because one of the officers wanted to tape the crime scene off to preserve evidence.</p><p>A lesser known line from the Hippocratic Oath goes like this:</p><p>“Into whatsoever houses I enter, I will enter to help the sick.”</p><p>Remember when you are on a scene, you are not just John Paramedic, you descend from Hippocrates and all who have held his faith. We are advocates for our patients. We stand up for them, bad or good, rich or poor, white or black, asshole or not.</p><p>You will have confrontations in this work. Stand tall. It’s okay to argue with the people with guns. They will respect you if you are professional and firm.</p><div><br /></div>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-63039650510470706302021-03-28T18:20:00.001-04:002021-03-28T18:20:14.458-04:00Bare Your Arms, Country<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-cTeHQ8NMfLI/YGEA-fOL4aI/AAAAAAAAG5U/i686oIbbgEEzpECLcFqFY3mk-Rrw4GoKACLcBGAsYHQ/s174/arms1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="174" data-original-width="169" src="https://1.bp.blogspot.com/-cTeHQ8NMfLI/YGEA-fOL4aI/AAAAAAAAG5U/i686oIbbgEEzpECLcFqFY3mk-Rrw4GoKACLcBGAsYHQ/s0/arms1.jpg" /></a></div><br /><p><br /></p><p><br /></p><p><br /></p><p><br /></p><p><br /></p><p>It’s back.</p><p>Two weeks ago, our hospital had 0 COVID patients admitted down from highs of 55 in April and 44 in December. Just like that we are back up to 12 in just a couple days. Elsewhere in Connecticut, the head coach of the woman’s top ranked basketball team missed the opening round of the NCAA tournament with COVID. Some girls my daughter plays basketball with had to quarantine due to exposure to people with COVID and on the COVID ACT Now, map, Connecticut has again turned red, signifying.</p><p>From all I have read, the cause is likely the arrival of the COVID variants that are more infectious than the original COVID. We are all hoping that our high and ever increasing vaccination rate (33% 1<sup>st</sup> dose/18.6% fully vaccinated) will soon overcome the variants, but we can’t be certain.</p><p><a href="https://www.courant.com/coronavirus/hc-news-coronavirus-daily-updates-0326-20210326-vzjc4qcgkjb37piu73enqvavii-story.html">Daily coronavirus updates: COVID-19 hospitalizations rising in Connecticut as variants spread; vaccine distribution skewed toward white residents</a></p><p>I am worried about the number of people who are still refusing to get vaccinated. It was a huge relief for me to get my shots, and I hope others will soon make the decision to bare their arms for their country. </p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-12624408002292513412021-03-26T07:52:00.003-04:002021-03-27T12:15:50.800-04:00Podcast-Saving Lives and Learning a Lesson About Addiction<p></p><div class="separator" style="clear: both; text-align: left;"><a href="https://1.bp.blogspot.com/-s4mUYgHTq8s/X6mxFN451ZI/AAAAAAAAG1M/QA5RELQ5X1A5XeBjYvcYXH04fiWULX-HwCPcBGAYYCw/s1600/canning.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1067" height="320" src="https://1.bp.blogspot.com/-s4mUYgHTq8s/X6mxFN451ZI/AAAAAAAAG1M/QA5RELQ5X1A5XeBjYvcYXH04fiWULX-HwCPcBGAYYCw/s320/canning.jpg" /></a></div><br /> <p></p><p>Just out, an interview I did with the <a href="https://theaddictionpodcast.com/?doing_wp_cron=1616737645.6110401153564453125000">Addiction Podcast</a> about my new book, <a href="https://jhupbooks.press.jhu.edu/title/killing-season/reviews">Killing Season; A Paramedic's Dispatches from the Front Lines of the Opioid Epidemic.</a></p><p><a href="https://theaddictionpodcast.com/2021/03/peter-canning-killing-season/?doing_wp_cron=1616745352.8232710361480712890625">Peter Canning – Saving Lives as a Paramedic and Learning A Lesson About Drug Addiction</a></p>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.comtag:blogger.com,1999:blog-8382523.post-18717177940400015252021-03-21T14:06:00.005-04:002021-03-27T12:28:25.951-04:00Opioid Epidemic/COVID Interview<div class="separator" style="clear: both; text-align: left;"><a href="https://1.bp.blogspot.com/-s4mUYgHTq8s/X6mxFN451ZI/AAAAAAAAG1M/QA5RELQ5X1A5XeBjYvcYXH04fiWULX-HwCPcBGAYYCw/s1600/canning.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1067" height="320" src="https://1.bp.blogspot.com/-s4mUYgHTq8s/X6mxFN451ZI/AAAAAAAAG1M/QA5RELQ5X1A5XeBjYvcYXH04fiWULX-HwCPcBGAYYCw/s320/canning.jpg" /></a></div><br /><div>An interview with me talking about the opioid epidemic in the shadows of the COVID pandemic appeared this morning on This Week in Connecticut with Dennis House.</div><div><p><a href="https://www.wtnh.com/on-air/thisweekinconnecticut/local-paramedics-first-hand-look-at-the-deadly-toll-of-drug-use-amid-the-pandemic/">Local paramedic’s first-hand look at the deadly toll of drug use amid the pandemic</a></p><p>Killing Season will be out on April 6, 2021.</p><p><a href="https://jhupbooks.press.jhu.edu/title/killing-season/reviews">Preorder Killing Season</a></p></div>Phttp://www.blogger.com/profile/16156697194234248490noreply@blogger.com