Narrative

 

 

Upon arrival found a 22 Y/O female unresponsive lying on the floor of her bedroom with her father performing CPR on her.

He states that he last saw her alive a hour ago and then found her on the floor unconscious before calling 911.

He states she has a history of heroin abuse and there is a used needle sitting next to her.

She is unresponsive, with no palpable pulse, and she is apneic.

 

52,404 Americans died of overdoses in American last year.  Some died in their homes and were found by family, others were found by strangers in places like public restrooms, parked cars and motels that rent by the hour.  We in EMS bear witness.

143 more Americans will die this way tomorrow.

 

High Risk

 

The dispatch is for an unresponsive overdose, likely fatality.  We are coming from a fair distance, but we are the only unit available.  There no updates.  No PD dispatcher asking if we are a medic unit or the message that CPR is in progress.  PD and fire have beaten us to the scene, but as we pull in, we know the story.  Friends and family members are gathered outside the triple-decker as word has no doubt gotten around the neighborhood.  The firefighter standing by the engine, nods to us.  A police officer comes out of the house and walks towards his cruiser.  I still grab my red in-house bag and cardiac monitor, and hike up the narrow stairs, and then through the open apartment door, down a hallway and into a bedroom where a man lays back against the bed like he was sitting up, and then just fell immediately backwards.  He has rigor and lividity.  Asystole in all three leads.  I announce the time.  It doesn’t take long to get the picture.  On a small table is a cardboard box, the kind glassine envelopes come in, and on top of the box is a small pile of white powder.  A broken off ballpoint pen case with which to snort the powder lies next to the box.  In the trash can is a torn heroin bag with a faded red stamp I don’t recognize.  Word is the patient overdosed a couple days ago and was brought to the ED.  In the corner of the room is a hospital gown with two electrodes still stuck to it.

Patients who have had a nonfatal overdose are at the highest risk of having a subsequent fatal overdose.  When a patient is brought to the hospital after an overdose, as long as they are alert and oriented, they are generally watched for a couple of hours and then discharged home, often with a mimeographed sheet of paper listing area treatment programs, many of which have long waiting lists.  Many patients aren't interested in getting treatment, particularly since the addiction and craving that brought them to overdose in the first place remains unabated.  Some hospitals in the country, try to get patients immediately onto suboxone or methadone, but not around here.  There is a lot of paperwork and regulations involved, and it is after all, dispensing an opiate, albeit one less deadly than heroin or morphine.

Most opiate users who EMS revives with naloxone and brings to the hospital are sent home or back to the street within 2-4 hours of their arrival at the hospital if they don’t leave AMA before then.

I don’t know the details of the dead man’s last experience at the ED, but I suspect it was similar.

New CDC Report: Characteristics of Fentanyl Overdoses

Yesterday the CDC released a fascinating new report, Characteristics of Fentanyl Overdose — Massachusetts, 2014–2016.

The Massachusetts Department of Public Health, the state’s Medical Examiner’s Office and the CDC gathered 20 heroin users from three counties (Barnstable, Bristol, Plymouth) with high fentanyl overdose death rates (Two-thirds of overdose deaths were attributed to fentanyl) and interviewed them about their thoughts and experiences with opioid overdoses.

While the fact that the respondents were recruited by local harm reduction coalitions, suggesting they were knowledgeable about overdoses and naloxone training, likely skewed the results, the results are still informative.

Respondents

95% had witnessed an overdose in the previous 6 months

42% had overdosed themselves in the previous six months.

88% attributed the rising death toll to fentanyl.

They often did not know if they had purchased fentanyl or heroin.  While some wanted fentanyl and others wanted to avoid it, the presence of fentanyl in the market did not change their desire for opioids. (This is a question I often ask users and have found similar replies).

30% said they always used with others to protect against a fentanyl overdose. (We have to increase this number).

Overdose descriptions

75% who had witnessed an overdose said fentanyl overdose occurred within seconds to minutes of use.

25% of the fentanyl overdoses with known route of administration were from snorting, 75% from injection.  In addition to unresponsiveness and apnea, they reported the following symptoms in some of the cases, immediate lip cyanosis, gurgling, body-stiffening and seizure, and foaming at the mouth. (I suspect the snorting route was higher as it is harder to find the paraphrenelia when the drug is snorted due to user disposing of the bag and delayed onset versus the more sudden and obvious syringe route.)

Naloxone

91% of them had been trained in the use of naloxone.

83% of those who had used naloxone said greater than 2 doses were needed before the patient responded. (My guess is that they did not wait long between doses to see if the first dose would work.  Three to five minutes can seem like forever in an unresponsive patients with decreased respirations.)

Fatal Overdoses (from a review of death records)

36% of the fentanyl deaths occurred within seconds to minutes based on death scene descriptions such as the syringe still in the arm or hand.

90% of the fentanyl deaths were in cardiac arrest on EMS arrival. (The most compelling argument for community naloxone).

68% of the deaths occurred in the decedent’s home, 18% in another private residence, 6% in a hotel or motel.

Only 6% of fatal overdoses had evidence that naloxone had been administered by bystanders.

18% of the deaths there was no bystander.  58% the bystander or family member was not in the room, 24% the bystander was unaware the patient had used drugs, 12% the bystander had also used drugs or alcohol, 26% the bystander did not realize the person was overdosing (they thought they were falling asleep or asleep).

Conclusion

"The high percentage of fatal overdoses occurring at home with no naloxone present, coupled with the rapid onset of overdose symptoms after using fentanyl through injection or insufflation, underscores the urgent need to expand initiatives to link persons at high risk for overdose (such as persons using heroin, persons with past overdoses, or persons recently released from incarceration) to harm reduction services and evidence-based treatment."

(Naloxone in a high dose concentration should be available in the medicine cabinet of any person with a known opioid use problem.  Training on recognition of overdose is vital.  Users should be counseled on the importance of never doing opioids alone.)

And are we ready for this?

"Findings indicate that persons using fentanyl have an increased chance of surviving an overdose if directly observed by someone trained and equipped with sufficient doses of naloxone. In some countries, including Canada and Australia, overdose morbidity and mortality rates have decreased in areas near supervised injection facilities where personnel are available to observe overdose onset, if it occurs, and administer naloxone as needed." Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend 2014;145:48–68 

Killing Time

 

A new legal strategy is to charge drug dealers with homicide when one of their customers fatally overdoses and it can be proven the customer bought the fatal drug from the dealer.

In Rhode Island this week a 25-year-old dealer was convicted of selling $40 worth of "Diesel" to to a 29-year-old customer who died 4 hours later.  The dealer was sentenced to 40 years in jail (with only 20 to be served).   One way to look at this is it sends a message to the dealers that they better think twice before they sell heroin in Rhode Island.  They are tough and bad ass on crime there.  They do not tolerate drug dealing.

You can read more about it here:

Drug Dealer Sentenced To 20 Years For Murder After Customer’s Fatal Overdose

In the story the dealer expresses regret.   “The actions that I did that day, I never meant to hurt nobody,” he said.  He apologizes both to the mother of the victim and his own mother.

The story mentions that the victim had just been discharged from drug treatment because her insurance would not pay for coverage past 30 days.  Having been in treatment, her tolerance was no doubt low and she likely did the same amount of heroin she used to do before going in to treatment.  People coming out of treatment are among the highest at risk for fatal overdoses because of their lowered tolerance.

52,000 American died last year and while I do not hold the 25-year-old drug dealer as an innocent participant, to me he bears a lot less responsibility for the death than the heads of the pharmaceutical companies who admittedly lied to the doctors and the public about the addicting properties of the drugs, and the DEA who approved the manufacture of increasing millions of kilograms of the prescription painkillers even when they knew the massive supply of painkillers was going to sketchy wholesalers who were flooding the black market with the pills, addicting and killing thousands of Americans while fueling an unprecedented heroin epidemic.  I know of no drug company executive responsible for the epidemic who has even spent one night in jail.  Sure, they were fined millions, but they made billions.

My main fault with the 25-year-old drug dealer was that he sold Fentanyl as heroin*, although it is not clear that he knew this himself.  How high on the chain was he?  Did he buy, cut and package the drug himself or was he given the powder by a higher up and told to sell it and bring back most of the profit to be passed up the line.  Of the $40 he received for the drug, how much profit did he make?  Certainly not the billions the drug companies made.  And clearly the victim was aware of the risks, although as an addict, she was likely powerless to rationally weigh them -- something known to the policy makers who created the system that kicked her out of treatment before she was ready.

Will the 20-year sentence slow the overdose death rate in Rhode Island?  We will have to wait and see.  I think it is less likely to slow it than increasing treatment options would slow the epidemic.  If the 25-year-old dealer had decided to work at McDonald's instead of in the drug trade, I think the 29-year-old user would have likely found someone else to sell her what she craved.

Here is an apocryphal story:

An old man sits on a bench in front of the courthouse, and sees the District Attorney.  “How goes the war on drugs?” the old man asks.  The DA says, “Great, we put twenty dealers away this week.  Sent them all to prison.”  The old man sees the DA the next week and says, “How goes the great war on drugs?”  “Outstanding,” the DA replies.  “We put thirty-seven dealers away.”  This goes on week after week, the numbers of arrests go higher and higher.  Finally, one day the DA answers the old man, “Best week ever.  We put away one hundred and seventy-eight drug dealers just today alone.”  The old man laughs and says, “Pretty soon, no more prison cells."

* He could have also have been more honest in labeling his product, calling it "Strike Dead," "Killing Time," "The Reaper," "Skull and Cross Bones," or "Dead Men," although likely his competing dealers had already claimed those brands.

Fountain

 

In Connecticut we are in the midst of hospital wars.  It is a very competitive market and all of the hospitals fight to attract patients.  You can see it on the billboards that line Interstates 91 and 84 with hospitals proclaiming themselves the best at heart care, stroke, trauma care or declaring they are the safest or provide the shortest wait times.  It can be seen even in EMS CMEs where medics and EMTs were recently treated to a lavish meal at one of the city's finest restaurants complete with free valet parking to hear a specialist tout a hospital's latest capabilities. (The event was subsidized by a vendor).  But nowhere is the battle more evident than in the TV commercials where hospitals tout their state of the art technology, their beautiful grounds and rooms, and the attractiveness (and wisdom) of their staffs.  It can make going to the hospital look almost like a trip to the Bellagio or some fine hotel with lavish fountains that go off at regular intervals.

Last Tuesday, my last call of a three day tour (I work three consecutive 12-hour days), we are in the triage line with our emotionally disturbed patient, coming on on a police paper.  I drove, my partner tecked so I don't have many of the details other than the young man is hearing voices and occasionally punches himself in the face, but for the most part he has come willingly.  No restraints, chemical or physical, were required.  We have been in line maybe 20 minutes so we are no longer outside the hospital or in the foyer, but within sight of the triage desks and the patients waiting in chairs and outside the first provider exam rooms.  My partner is waiting to give his report.  I stand by the head of the stretcher, checking my i-phone for the time.  Hopes of getting out early are lost.

An old woman on a nasal cannula sits on a chair outside an exam room and is suddenly yelling at me.  "Stop that!  Stop that!  Do something!  Do something!"  She looks very angry.  I have no idea what she is upset about.  No one else seems concerned.  Is she just another psychiatric patient hearing voices and talking to herself.  "Stop!"  she shouts.  "Have you no decency!  Stop!"

I look at her closely.  Her anger is not abating.  Then I look at our patient. He had his penis out and is urinating straight up into the air.  The golden liquid is arching up , then falling back down splattering on the patient himself.  A fountain.

"Do something!" the old woman shouts.

For a moment, I think "What do want me to do?  Is this my fault?"

But then I realize, I can probably take some action to alleviate her distress.  I grab a sheet from the back of the stretcher and throw it on top of the patient's offending part.  "Knock it off!" I say.  He mumbles something incomprehensible, then punches himself in the face one time as if he is admonishing himself for his bad behavior.

The woman is still glowering at me.

"Sorry about that," I say.

What I really want to say is: "So they left that part out of the commercials."

It is an hour before we get the patient off our stretcher and leave him in the psych ward where the staff are wrestling with another man and from deep in the bowels of the ward we hear another patient chanting  "Bin Laden!  Bin Laden!  Bin Laden!"

Welcome to the ER.

Clean the stretcher, sanitize the straps.  We get out an hour late.  The ambulance goes back into service with a new crew, ready to take the citizens of the area to the destination hospital of their choice.  Enjoy your stay.