EMS Distributes Naloxone

 

Paramedics in North Carolina and in Cleveland, Ohio are providing Narcan kits to high risk patients in their communities.

Cleveland EMS Providers to Distribute Overdose Kits

N.C. County Allows Paramedics to Provide Precautionary Narcan Kits

My partner and I often spend time on heroin overdose calls educating the patient's family, friends or bystanders/social circle on the availability of Narcan (where to get it -- local clinic, pharmacy, etc) and how to administer it. We recently had one patient's neighbor (who had found his friend unresponsive) express gratitude for our lesson and say he would immediately go down to the clinic and get a kit. A woman this week told us she had Narcan in the bathroom, kitchen, living and bedroom in her apartment, and had one kit always in her purse (which unfortunately had been taken from her while she nodded off in the bushes -- thus prompting the 911 call for the woman unresponsive). Leaving a Narcan kit with people who were present at an overdose scene makes clear sense.

If we had Narcan kits that we could give out, we could easily disburse them to high-risk individuals.

In North Carolina, EMS is giving Narcan to patients who refuse treatment. I have not had a patient in years who refused treatment after Narcan.  Many years ago when my practice was to give 1.2-2.0 mg IV, I did have quite a number of patients refuse. Well, instead of saying, I refuse, they used more colorful language as they ripped the IV out of their arms and walked down the street the colorful language continuing. Now, I mainly use Intranasal (IN) Narcan or IV at very low doses (0.1 increments), and my patients are much more subdued, and go to the hospital. The ones that refuse are the ones who are simply on the nod, and who wake with stimulation (like the woman in the bushes, who actually was roused by a bystander as we arrived, and started walking down the street on her own, although she did stop and let us talk with her).

If opiate overdose patients are going to refuse transport, leaving them Narcan as well as persuading them to have a friend watch them for awhile seems reasonable.

We did have an very interesting conversation with the woman, who not only told us what brand of heroin she had used, she provided commentary on a number of different brands we had seen. She told us that she avoided Chief and OMG because they were white heroin known to be mixed with Fentanyl. She preferred the brownish powder. Every time she foolishly tried white powder brands, she said, she ended up surrounded by firefighters and EMS. She wasn't looking to die nor was she looking for a magic high. She just needed her daily fix, and for that she had to walk to Park Street everyday to meet her guy.

She got hooked on heroin because it was cheap and she had issues of loneliness and self worth that had caused her to seek escape. She uses heroin every day now. It is as much a part of her life as getting up in the morning, drinking water, eating her daily bread, and forgiving her trespassers.

Kudos to North Carolina and Cleveland.

Park Street

 

I only went to one heroin overdose this week and one PCP overdose.  The heroin overdose was on Park Street in the South end and the PCP was on Capen in the north end.  You get get called for an overdose on Park Street and it is pretty much always heroin.  You get called for an overdose at Garden and Capen, it is going to be PCP. The North end is mainly black, the South end Hispanic.  The blacks control the PCP trade, the Hispanics most of the heroin. There is some mixing, but that is pretty much the divide. You go to Keney Park in the north end, and you find lots of tiny empty clear plastic baggies with no markings. PCP. Not too many heroin bags. You go to Pope or Colt Park in the South and you will find empty glassine envelopes with stamps on them marking the heroin brands.  In just one month of looking, I have already counted 96 different brands (some of the envelopes are likely months old (one was branded Super Bowl 50), others freshly tossed from the car window where the junkies sit low in the seats shooting up, and chilling before driving off).  Some brands I have only found one of, others are scattered everywhere, often in clumps of five or more bags.  I find it fascinating to see what brands are the hottest. Black Jack gave way to OMG, which gave way to Chief, Public Enemy, and now to Fastrack, which we found in nearly every location we looked last week.  Who knows what next week's hot brand will be?

The heroin overdose I went to was a woman I had treated before. She had gone into a public restroom and not come out. When the first responders got there, she was unresponsive and blue. The fire department gave her 2 mg of Narcan IN. By the time we got there, she was already in the back of the BLS ambulance, breathing on her own, and rousable with a good shake. She was in her thirties, wearing a short skirt and a low cut top with a pushup bra. At one time had obviously been good looking, but there were hard miles on her. She had cellulitis and abscesses on her arms and a bad ankle that had never healed right from a fall. When we put her name in our laptop, her address came up in as a Hartford suburb, but she said she was now homeless. I tried to ask her some questions about what brand she had used, but she kept nodding off. She was at least able to identify the Fastrack brand from the picture I showed her on my iPhone and say she heard it was dangerous. She told me she bought from her usual dealer.  I asked her again what brand she had used, and she said she was trying to remember, then she nodded off again. I let her sleep. Her ETCO2 was 42 and her SAT was 96 on room air, her respiratory rate was 14. Power to her. At the hospital, they said they were going to give her more Narcan. I guess they were pretty full and didn't have a sitter to watch her sleep in case she started hypoventilating again. 

The first time I picked her up was in front of the shelter at Hungerford and Park. The police officer who flagged us down said she was drunk. She was motherfucking him to beat the band. My BLS partner said he would tech the call, and after having teched the first nine of the day, I let him. I drove to the hospital and saw him typing the PCR on the computer. When we hit the hospital, and pulled the stretcher out, she was cyanotic, and breathing maybe four times a minutes. I shook her shoulder and she roused enough to tell me to fuck off. I saw the fresh needle mark on her right hand then, the pin point pupils, and was upset with myself for just assuming she was drunk and not taking a closer look just walking to get in the driver's seat when my partner offered to do the call.  

I debated pushing the stretcher back in the ambulance and giving her Narcan then, but since she was rousable we just brought her in.   Unfortunately the triage line was long. Every couple of minutes I had to shake her hard to get to breathe. After awhile, she stopped swearing at me, and I had to cut to the front of the line and ask the triage nurse for either Narcan, an ambu bag or permission to go back out to the truck to get my gear and treat the patient in the their waiting line. They wanted us to bring her to the critical room, but I said she just needed a little Narcan so they finally gave me an ambu bag and a room down the hallway where a nurse practitioner asked us what the dose was. We told her to start low. They gave her 0.4 IM, and took over bagging.  I thought next time I would just go back out to the ambulance and get my gear.  We saw our patient later smoking a cigarette in front of the ED, the hospital ID bracelet still on her wrist.  She didn't recognize us.

I wanted to go back and talk to her after we left her in the room this last time, but we didn't get back to that hospital till four hours later and she was already gone.  I went back to the restaurant where she had ODed in hopes I could find the wrappers in the bathroom, but they had a men's and a women's bathroom, and you had to get the key from the guy making the sandwiches.  I chickened out and asked for the men's room key after buying a turkey sandwich.  I suppose I should have just come out and said I wanted to look in the woman's room to try to identify the brand the woman had ODed on.   I did find two wrappers in the men's room, but they were blank.  Not all the bags have stamps on them.

I have seen her a few times walking along Park Street, particularly in the early morning when the bakeries are just opening up.  They sell pressed bologna sandwiches real cheap and there is often a line out the doors. One of the bakeries sells a pernil (pork) cubano for only $3.  I try to get one if the line isn't too long.  Some mornings they sell homemade tamales wrapped in corn stalks. $0.75. They are run by honest people, and feed many in the community.  There is drug dealing close by but that comes with the territory of Park Street.  Everyone likes sandwiches and cheap coffee and a friendly smile in morning.  Cops eat there, EMS eats there, working folks eat there and drug dealers, junkies and the homeless eat there. We all have our roles. Such is the community of Park Street, the community of Hartford.

Public Enemy

 

Last week I speculated that despite increased access to Narcan, the opiate epidemic would continue to rage with deaths in 2016 exceeding those of 2015.

Narcan Thoughts

Sadly, this was borne out in just released data from the state medical examiner. Through the first six months of 2016, 444 people died of fatal overdoses in CT, which projects to at least 888.  729 died in 2015.

A story in the Hartford Courant lays much of the blame on Fentanyl , which was involved in 25.8% on the deaths in 2015, and already in 50.2% on those in 2016.

Fueled By Fentanyl Spike, Overdose Deaths Continue To Climb In Connecticut

How powerful is a drug that you know can kill you easily, and yet you still take it -- often alone with no one to watch over you?

It isn't a slow death like that one inflicted by cigarettes or gluttony. Most of us have encountered the dead with the needle still in their vein.

To many people giving Narcan to EMTs and to family members was a drastic step, unheard of a few years ago. Maybe we need to think even bolder.

Maybe we should as some other countries do and have safe havens where junkies can go for their daily fix and be observed by medical personnel with Narcan at hand. They can get access to people who will try to convince them to get treatment.

William Proxmire, a former United States Senator, who was a big advocate to eliminate wasteful spending, used to say, " a million dollars here, a million dollars there, and pretty soon you are talking about real money."

To paraphrase for the opiate epidemic. "A hundred opiate deaths here and a hundred opiate deaths there, and pretty soon you are talking about a massacre."

Here is an interesting article on heroin safe havens.

Boston's Safe Space for Heroin Users

"It's not that we don't want people to be drug free. But dead people don't recover." -Barbara Herbert, the president of the Massachusetts chapter of the American Society of Addiction Medicine

Public Access Narcan

 

Medical emergencies, like cardiac arrest, anaphylaxis, heroin overdose, (and being bitten by a Black Widow spider), require quick treatment to save a life.   Our public health system recognizes this.  We have AEDs, epi-pens and now increasing access to Narcan. All great initiatives.  Before I advocate for public access anti-spider bite kits, let me address Public Access Narcan.

Public Access Defibrillators are put in spots where patients are more likely than others to suffer sudden cardiac arrest.  We see public access defibrillators in airports, casinos, health clubs and in town halls, outside the tax assessor's office.  Epi-pens are given to school nurses in case students with allergies to substances like peanuts have sudden anaphylaxis. These devices have been credited with saving many lives.  I wonder how effective or realistic a public access Narcan program would be. I would not put Narcan in health clubs or outside the tax assessor's office, but I might consider putting it in the bathrooms of establishments like fast food restaurants and laundromat in certain areas of town.  I have not yet responded to an overdose at a school, but there have no doubt been overdoses at schools, likely more than sudden cardiac arrests.  If they can have AEDs and epi-pens in schools, they surely have room for a dose or two of Narcan.  I would put Narcan there, and I would put Narcan by the clerk's desk at low-rate motels. I would put Narcan on city buses (done a few on these) , and in the gazebos of city parks. I'd even put one in the Zion Hill Cemetery based on the drug paraphernalia we saw when we drove through it one morning last week before the daily caretakers had swept the place.

I am very impressed that Massachusetts is able to record and report on the number of patients who receive Narcan from EMS responders. It likely wouldn't be too hard to track the zip codes and addresses of all the Narcan administrations.  Certain blocks could qualify for a Narcan alarm box on their street corner. Of course, you would need to configure the box so when activated, it would notify 911 to get EMS rolling. If the address was near a bar or nightclub, you could even consider putting Narcan in vending machines in bathrooms next to the condom or tampon machines.

In Connecticut Narcan is sold over the counter in pharmacies and often given away free at inner city clinics. But for those who frequent the night, maybe Narcan could be made available at grocery and convenience stores around the clock. They could sell it by the register or perhaps in another place people likely to deal with a heroin overdose might look, next to the ice machine.

I have never treated a patient bitten by a Black Widow spider, but I did treat a patient who used the powder that came in the pictured glassine bag.

The Finger

 I have been injured seriously enough to miss work twice in the last two decades.  Neither time was I injured on the job.  The first injury was playing softball on our ambulance team (back when we had one). I went from first to third on a single, and as the third base coach signaled me to slow, I stumbled coming into the bag, lost my balance, and landed on my outstretched hand, breaking a small bone in my wrist that required me to wear a cast for six weeks.  

A year or so earlier, I had broken the ring finger of my right hand at the top joint, playing basketball (going up for a rebound -- the ball hit the tip of my outstretched finger), but never had to miss work, as I was able to wear a splint that only immobilized the top joint, and enabled me to to still do IVs, lift and carry.  My finger is still slightly bent to this day.

I stopped playing basketball (for fear of injury) after that until a few years ago when our company, which does standbys at the Civic Center, organized a basketball game between divisions to be played on the Civic Center court (albeit before 12,000 empty seats).  I was enticed to join the team thanks to my height (6-8).  While I enjoyed myself and did quite well, largely thanks to hustle (I was running half marathons at the time and could easily out run most of the other players), I took a head butt to the chest in a scramble for a ball, that knocked the wind out of me.  I was able to keep playing, but it left me unable to sit up in bed at night without using a pillow to splint myself and it prevented me from doing push ups as I felt like my chest was going to split in two.  My diagnosis -- I think I cracked my sternum.  I never saw a doctor about it, but it was almost two months before I was pain free.  Still, I worked through it.  Never missing a day.

Recently I sustained another sports injury. I mainly swim now for competition, and in the last event of my last meet, I slammed my hand into the electronic pad at the finish (I had been upset that in two earlier races, the electronic pad had me slower than the hand timers who had clocked me in personal records.  So I hit the pad a little harder than I should have.  I did not feel any pain, but soon noticed the last joint of my middle finger flexed, but could not extend.  I had what is called a Mallet finger -- a ruptured tendon. My initial splint immobilized the entire finger, leaving me unable to work for two days until I saw a specialist who fashioned a splint enabling me to work, as long as I tape it up well. I can still do IVs and lift, but when I lift, I cannot use that finger which remains in a modified bird position.  I have to wear the splint for 6-12 weeks in hopes that the tendon will reattach.  If I move it too early, it is back to square one and another minimum of six weeks is required.  I have banged it a few times and had it squeezed twice in a wrestle with a patient, but for the most part I am hopeful it is healing. Surgery is an option, but the splint method actually has a higher cure rate that the surgery.

At work, we have a time clock where when punch in or out, you put in your Kronos number, and then place a designated finger tip on the scan button. When you first logged in to the new system, it let you choose which finger you wanted. Most people chose their middle finger. I thought about it, and while I appreciated the humor, I did not choose my middle finger.  I did the pointer finger instead.  And while I admit, there are days when I want to give the bird to work at the end of the day, I still maintain respect for the work.

When I was a kid, one of my favorite tales from the excellent American Folklore picture book I had was the story of Joe Magarac, the man of steel. Joe was the best worker in the steel mill.  He could do the work of twenty men. Then one day, there was talk of closing the mill, so Joe jumped into the vat and melted himself down into steel, and his steel was of such high quality that they built a new steel mill with his steel and everyone's job was saved and the town prospered.

I am not saying that we should all sacrifice ourselves for our companies (neither should we give them the finger).  If we do sacrifice ourselves, it should be for the idea of work and the idea that work and caring about your work has value.  Caring -- no matter what the object -- is what brings value to our lives.