Sunday, December 23, 2018

Manual Versus machine Blood Pressures

 

How do you want to be known as a Paramedic/EMT?

A. Reliable
B. Frequently wrong

According to a recent article in JEMSDitch the Machine to Improve Accuracy in Blood Pressure Measurement and Diagnostics, "automated blood pressure readings are frequently inaccurate."

Is this a surprise to anyone?

Yet, many of us continue to relay on automated BP cuffs to direct our clinical actions.

In a March 2016 article in the Journal of Clinical and Diagnostic Research, Which is More Accurate in Measuring the Blood Pressure? A Digital or an Aneroid Sphygmomanometer:, digital devices:

  1. should be used with caution, doubt and suspicion
  2. are not up to standard
  3. (can cause many people to be) wrongly or misdiagnosed
  4. may prove disastrous

Powerful words.

The JEMS article points out that even the manual for the Physio-Control Lifepack 15 contains this warning:  

"shock may result in a blood pressure waveform that has a low amplitude, making it difficult for the monitor to accurately determine the systolic and diastolic pressures."

Got that.  Your Lifepack 15 is not capable of providing reliable blood pressures if your patient is in shock.

Cardiogenic shock
Hypovolemic shock 
Anaphylactic shock 
Septic shock 
Neurogenic shock

Your machine BP is unreliable when addressing these conditions.  It is frequently wrong.

How are you going to make clinical decisions with bad data?

You need to take manual blood pressures.

As an EMS Coordinator, I see run forms with blood pressures like these:

158/71
210/190
143/84
95/87
170/119

All for the same patient.  With no explanation.

As a paramedic, I have had my patient in afib brought into a level one medical room because the triage BP machine said my patient had a blood pressure of 79/40.   Why are we in here? the doctor asked as he looked at my calm, warm, dry patient.

Because the triage system at this hospital relies on digital blood pressures. 

Don't relay on machines to take a blood pressure in patients with atrial fibrillation.

Here are my guidelines:

  • Make your first blood pressure manual
  • Treat your machine pressures as an inexperienced partner
  • Before making a critical clinical decision, take another manual pressure.

Make certain you know how to take a proper blood pressure.

Here are some good articles to help us improve our manual blood pressures:

Taking a Manual Blood Pressure: Techniques & Pitfalls

Blood pressure reading tips and tricks for EMS

 

I get it.  It is hard and nearly impossible sometimes in EMS to obtain optimal conditions for taking a blood pressure.

Just know that the blood pressure you obtain under those impossible conditions (using short cuts) may not be accurate.

Don't let inaccurate and unreliable readings cloud your clinical judgement.

Take a manual, and if you can't hear, palpate a blood pressure.

 

 

 

Tuesday, December 18, 2018

Balance

December 8, 2018: This weekend, I am in Worcester, Massachusetts at the New England Short Course Meters Masters Swimming Championships as a member of the Connecticut (CONN) team. Last year, we shocked many of the other teams by taking first place. Points are awarded based on place finish in individual and relay events. Each swimmer is only allowed to swim a maximum of six events a day or 13 for the entire meet. Friday evening is distance day (800 Free), Saturday and Sunday are for the relays and the main swimming events. Last year I scored 119 points swimming 12 events despite having a pretty severe chest cold. I also swam in three of the four relays. I came in second in the men’s 55-59 200 Meter Butterfly and earned 15 points for it. I was second out of 2 swimmers. Last year I finished 25th in the nation in that event in my age group. 25 out of 25. Still I was proud as it is a difficult event, particularly for someone who did not know how to swim the stroke five years ago. I am swimming it again this year, and if all scheduled swimmers swim, I will likely finish 5 out of 5, but maybe some of them will scratch (drop out) as it is the last individual event. Last year I swam the full 200 meters without stopping. This year I may hang on the wall and catch my breath at some point along the way. I have not trained as much this year as last. My best event is the 50 free, but I will not come close to my best time of two years ago. Again, lack of training time and intensity. Plus Father Time sapping some of my strength.

Joe Frazier used to say. “If you cheated on that (your roadwork) in the dark of morning, you’re going to get found out now, under the bright lights.” I have no cold this year, but I am a year older, and not in the shape I used to be. That lack of training is likely to be apparent. Still I am here as part of a thirty person contingent of people who I have come to call my friends over the years. No matter how fast or slow I swim, i always get high fives and good jobs. I doubt we will win this year. Charles River Masters, who we upset last year, showed up loaded with more swimmers. My goal is to score more points for my team than last year, which will be a little easier as I am swimming one additional event and I have moved up in age to the 60-64 division.

Here’s why I writing all this on my EMS blog.

I was talking the other day with a new medic trainee and we were talking about a number of the old career medics who were around when I started, and I told her of how many of them ended up broken. Here’s a roll call. Overweight, fired for poor behavior, dead of a heart attack. Fired for violating policy, seen a few years later in a nursing home with jaundice, dead not long after. Retired unceremoniously, dead within months of lung cancer, obit posted on the operation’s wall. Fired for undisclosed reasons, shot dead by police in a standoff -- suicide by PD. Left for undisclosed reasons, found dead in bed a few years later, obese, uncertain of heart attack or overdose. Not a lot of happy stories. Many say that the job will leave you bitter in the end.

I used to say that I wanted to stay at this until I am 72 when my youngest daughter is targeted to graduate from college. I don’t know if I can make it make it that long. I am hoping to at least stay full time until my middle daughter who is a freshman at college graduates. My goal is to get her through without any debt. In addition to my medic job, I also work as an ems coordinator at a local hospital. Between the two I am scheduled for 64 hours a week, but I often work longer. I try to keep Saturdays as a day for my youngest daughter and I to do things together.

My youngest is very into sports, and unfortunately, tomorrow, she has her first basketball game of the season, and I will miss it because I am here at the meet. She is playing in two leagues this winter, one with Saturday games and one with Sunday. Other than today, I will be at all her Saturday games, but because I work Sundays, I will only be able to see the Sunday games if I take off work. A part of me wants to go part-time on the ambulance so I can be free to see all her games, but with the middle daughter in college, I can’t really afford that yet. I debated not going to this meet, but last year I skipped several meets to see her games. The fewer meets I do it seems the less I train. This is the one big meet of the year, so I expected if I skipped it, my identity as a masters swimmer would pretty much slip away, and I am not yet ready to give that up. I need athletic competition to keep me healthy and maintain my image of myself as an athlete and a man still in prime health.

All these conflicts.

I used to never miss an ambulance shift. I prided myself on always being on time and always being there if my name was on the books. In twenty-five years I have only had to go home sick twice, and only called out sick about the same number. I have only been late three times, twice due to a time change and once due to my alarm not going off. I take days off fairly freely now. With my seniority, I get a ton of PTO, so I use it. I took off for Zoey’s soccer championships and I will certainly take off for her basketball championships if she makes those. My next swim meet is Superbowl Sunday and I am planning to take off for that, but only if it doesn’t conflict with one of her games. I’ll take that game over the local meet. Hopefully, I’ll be able to do both.

I enjoy my swimming friends, as I enjoy my EMS friends. And of course, I enjoy my family most of all. Between the three I hope to be able to maintain a balance that I have not always had. I don’t need to be on the ambulance everyday or at every swim meet or at every single one of my daughter's games. I just have to do my best to be there whenever I can, and ensure that I am healthy, and happy. I want to be there for the long run.

Postscript:

We came in 3rd in the meet. I had the eighth most points of any male in the competition, points mainly accumulated because I was one of a few who swam 13 individual events. I finished the 200 Butterfly only a few seconds slower than last year, and captured 3rd place. Out of 4.

My daughter won her game and scored 8 of her team’s 14 points. Hearing her recap of the game wasn’t as good as being there, but it was still great. Nothing much of interest happened on the ambulance that day, according to the guy who filled in for me, nothing unusual. I didn’t miss out on anything exciting.

The meet renewed my enthusiasm for swimming, so I have been hitting the pool hard this week. I saw my daughter’s game yesterday and it was great. They won and she played well, scoring 10 or 12 points in the win, including making both her free throws. Not bad for 10 years old.

I am at work now, posted on a street corner in the December rain, drinking hot tea with honey.  I am hoping the next call will be an interesting one.  I hope that I get out on time so I can swim at the pool.  I hope that when I get home, I will sit in my armchair and have a cold glass of water, while my wife sits on the couch and laughs at Will Ferrell in the Wedding Crashers in a way that brings warmth to my heart.  I hope that my daughter will be dribbling her basketball back and forth between her legs.  I hope that she looks up at me and says “Dad-Catch!”

 

  

Thursday, December 06, 2018

Not My Addiction

 

This is great film, made by EMS for EMS, to help us understand addiction and the stories behind our patient's lives.  The 37 minute film tells the story of four addicts in their own words, including one who was once in EMS.  Listening to these four tell their stories helps people understand how easy it is for a person to fall into the grip of opioids and how hard it is to get out.  As I mentioned in another blog post, I recenly heard a mother describe her daughter's descent into opioids, which ended in her death, as "an innocent entry and an impossible exit."

I met two new young people this week who were ex-addicts struggling to reclaim their lives.  One was a former army medic, who told me he became addicted in Afghanistan. His squad often found caches of heroin, hidden by villagers. It was hot there and they were always hydrating themselves with IVs.  One day they added a few grains of heroin to the IV.  Three days of this and he found himself coming down with a horrible flu.  It took awhile for him to realize he was in opioid withdrawal.  When he came home, he found himself in Hartford, a land where a bag of heroin is only $4.  Two years of hell later, and scared by two fentanyl overdoses, he finally got on suboxone, which is working for him.  Still he's a homeless vet, and he has a long way to go to truly be back home.

The other young man got hooked on prescription pills after an injury.  He followed the usual course, buying on the street when his prescription ran out, and switching to heroin because it was so cheap.  The death of so many of his friends got him onto methadone, and that too, is working for him, although like the soldier, he is homeless and living in the woods.  We talk for a long time, and I tell him how my views on addiction have changed over the years and how I now recognize it as a disease.  "You should talk to my parents," he says.  

Watch the film.  Educate yourself.  Talk to people.  There are a lot of lost souls out there who can use our help.  

Not My Addiction

Review: Documentary film takes EMTs, paramedics inside the pain of opioid addiction

Wednesday, December 05, 2018

Opioid Crisis National Roadmap- EMS Comment

 

EMS Encouraged to Comment on Opioid Crisis National Roadmap

These are my comments on the draft report developed by the Fast Track Action Committee (FTAC) on Health Science and Technology Response to the Opioid Crisis.

People who have suffered a nonfatal overdose are at the high risk of suffering a fatal overdose. A recent study out of Massachusetts suggested that one out of ten of these patients will die of an overdose within a year.(1) Since EMS has contact with these patients at a pivotal time in their live, EMS has an opportunity for intervention either through educating them (and their families)to rehab options or where to obtain naloxone and clean needles for those who are not ready to quit. Some EMS services even leave naloxone with users and their families.
The manner in which EMS treats these patients is also critically important. If EMS treats them as people who are suffering from a chronic disease as opposed to people with character flaws, then they can help reduce the stigma that any opioid users face that can be a barrier to them seeking help. Improved education for EMS personnel into the science of addiction is needed if EMS is going to play a role in helping people toward recovery.

Harm Reduction should be emphasized in EMS education and in EMS Treatment. In area of high intravenous drug usage, designated EMS vehicles or stations could function as a needle exchange site, providing users with clean supplies as well as information about rehabilitation. Clean needles and supplies will not only help the spread of disease such as AIDS and Hepatitis C, it can prevent endocarditis and other infections that are rampant in the user community.

EMS data offers as unique look into the epidemic and can provide real-time data surveillance and early warning of spikes in overdoses and bad batches if done properly. A study from North Carolina has shown the naloxone is a poor surrogate for tracking opioid overdoses because many overdoses do not need naloxone and that naloxone is often given to people who turn out not to have opioid overdoses. (2) A better way is to require EMS to install the data element “suspected opioid overdose,” and track this. In Connecticut, we have conducted a pilot study of using our Poison Control Center as a repository of EMS overdose information. In the pilot, EMS responders in Hartford called poison control shortly after each overdose they responded to, and answered a series of questions about the overdose, including patient demographics, place and route of overdose, whether naloxone was needed and in what dose, and identification of any paraphernalia. (4) The project is expected to slowly expand statewide, and will eventually be linked to the HIDTA (High Intensity Drug Trafficking Area) OD map software to show location of overdose. (3) The project was able to identify unique heroin brands linked to overdoses as well as information about users who thought they had bought cocaine, overdosing on opioids.

Emergency Medical Services, which has been underutilized in the fight against the opioid epidemic, can be a leader in the fight contributing surveillance, data collection, and early warning alerts, as well as education and harm reduction to the traditional role of emergency treatment.

1. 402 One-Year Mortality of Opioid Overdose Victims Who Received Naloxone by Emergency Medical Services
Weiner, S.G. et al. Annals of Emergency Medicine , Volume 70 , Issue 4 , S158

2. Joseph M. Grover, Taibah Alabdrabalnabi, Mehul D. Patel, Michael
W. Bachman, Timothy F. Platts-Mills, Jose G. Cabanas & Jefferson G. Williams (2018)
Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid
Overdoses in a Large U.S. EMS System, Prehospital Emergency Care, 22:3, 281-289, DOI:
10.1080/10903127.2017.1387628

3 https://www.hidta.org/odmap-training/

4. https://www.courant.com/news/connecticut/hc-news-hartford-overdose-tracking-numbers-20180912-story.html

 

 

Down Time

 

A few days ago on our employees only Facebook page, someone posted a picture another person had taken of one of our crews while they were parked by the side of a street. The driver leaned against the window, arms folded, eyes closed.  The passenger had his eyes open, but he was slouched down in his seat. They were clearly in rest mode, but it wasn't like they needed Narcan.  The comment was if they wanted to sleep, they should find a more secluded spot than a downtown street. The concern was every crew represents all of EMS, and the poster thought this crew looked unprofessional.

A fair point, perhaps, but I admit I felt bad for the crew to be shamed by a few fellow employees (the comments mainly agreed with the poster).  There are few days I have worked when either myself or my partner have not been guilty of shutting our eyes at some point in the shift. I can’t say there hasn’t been snoring at times. (Most in EMS work either mega-overtime or multiple jobs in addition to trying to raise families and fatigue in EMS has been well-documented in the literature). It's why I like to find out of the way spots. Not that we get a lot of downtime. Our service utilizes system status management so we are constantly on the go. If you are not on a call, you are headed to a posting location to wait for a call, and sometimes sent to another location as soon as you arrive at the first one. At least our management is not too rigid about where we post as long as we are in proximity to the stated posting location.

I am six-foot-eight and sixty years old so it is almost impossible for me to sit folded up in the passenger seat for too long. I have to get out and stretch. I bring a basketball with me and sometimes will find a court to shoot on (my radio on my belt), or I will just stand outside the ambulance practicing spinning the basketball on my finger. I took my daughter to see the Harlem Globetrotters last year and have challenged myself this year to master the finger spin. My goal is to have my picture taken with a Globetrotter with both of us smiling while spinning basketballs, during the pregame photo session. I have already purchased the “Magic Pass” tickets.

The other day, my partner and I were in Bushnell Park (covering downtown) and a local TV cameraman showed up to take some footage of the park ambiance and scenery. When he was done, putting his camera back into his truck, which was parked right behind us, he told me the film was for the weather segment. He said not to worry. He didn’t take any footage of me spinning the basketball as he imagined if my boss saw it, my boss would call me into his office and ask me to bring my basketball.  He thought he was doing me a solid, but I was disappointed. I had imagined calling my daughter and saying be sure to watch the weather tonight, you’ll see a basketball superstar doing tricks. The cameraman didn’t understand. The fact that I am standing outside the ambulance spinning a basketball doesn’t mean I am lazy or goofing off. It's just what I do sometimes while waiting for a call.

I feel the same about the crew that was getting some rest. What matters to me, at least, is not whether they are sitting bolt upright in the seats, eyes open, hands on the steering wheel and the map book ready to respond, but that when their number is called, they hear it, answer the radio, respond quickly and safely, and treat their patients with skill, kindness, and empathy.

Peace to all.

Fighting Fatigue in EMS

Fatigue in EMS

Harlem Globetrotters Magic Pass

Wednesday, November 28, 2018

Beautiful Boy: The Book

 

In the movies, the hero kills the monster after an exciting and lengthy battle. Then just as the winning team congratulates themselves on their great victory and now bright future, the monster raises its head again. It was not really dead! After a brief but tense battle, in which the hero almost dies, the final sword is plunged in the monster’s heart. The movie is over. The credits roll. Hooray. Peace on Earth. A predictable formula.

There is a new movie out about addiction. Beautiful Boy stars Steve Carrell, the comedian of The Office fame, who has made quite a number of excellent serious movies. The movie is based on the book Beautiful Boy: A Father's Journey Through His Son's Addiction by David Sheff about dealing with his son Nic’s addiction.

Nic is wonderful child, who suddenly turns into a crystal meth addict. It seems suddenly to the father, but it is a little more gradual. Unbeknownst to Dad, the boy starts smoking pot at 13. It makes him feel fantastic. He has some underlying and undiagnosed mental health—he’s bi-polar-- issues that the drugs help him deal with ( at least initially, before exacerbating the problem). He battles the addiction monster until at last it is slain and he is back in the family’s graces. Then predictably there is a scary relapse. But he again beats the drug monster. So far so good. But the book doesn’t end there, not even with the wonderful letter he writes to his family and little brother and sister about his love for them and the sorrow for all the troubles he put them through. The monster raises its head yet again. Not really dead.  And again, and again, and again. It happens so often I lose count of all of the relapses. Really? Not again. Ultimately, the boy, now a young man, ends up drug free for eight years and he is still apparently drug free as of the publication of the latest edition of the book.

I haven’t seen the movie yet, so I am curious to see how they will handle the real-life story that doesn’t fit the typical Hollywood plot.*

The book is worth the read, and it clearly shows how relapse is part of the addiction, and that finally, after years of struggle, it is possible to get clean. The son, Nic, has written two books himself covering the same material from his point of view. These books were written prior to the publication of Beautiful Boy. The first book, Tweak: Growing Up on Methamphetamines, ends with Nick clean. Predictably, the second book recounts further relapses. I have just finished reading Tweak, and am not certain I have the stomach to read the second. He writes very well – at times his book reminds me of Jack Kerouac for its adrenaline-fueled narrative of Nic’s adventures while high, but like his father’s book, after a while, it becomes tedious. Nick is not particularly likable, and while he accurately portrays the user’s self-centered need to stay high, it is a bit hard to take. You just want to shake him and say, get a grip. But again, that is the nature of addiction – people doing things that they know are against their best interest because their brains are diseased and they no longer think properly.

I am going to pass on Nic’s second book, We All Fall Down, but will definitely try to watch the movie. I am also currently reading the father’s second book Clean: Overcoming Addiction and Ending America’s Greatest Traged, which is about how the country can best treat (and prevent) addiction. It is well-done and quite scary for the father of a ten year old to read about all the dangers that may lay ahead of her in the world outside the cocoon of our happy home.

*I am hoping the multiple relapses will be in the notes at the end. It is hard enough to live through in a book, I can’t imagine the toll it takes on a parent to live through in real life.

 

Thursday, November 15, 2018

Plateau

 

Plateau -(noun) “ a usually extensive land area having a relatively level surface raised sharply above adjacent land on at least one side.”

Plateau-(verb)- to reach a level, period, or condition of stability or maximum attainment,

Merriam-Webster

***

The United States Health Secretary announced recently that the opioid overdoses deaths appear to be plateauing across the country.  While some states have seen a decrease and others an increase, the overall numbers appear to have slowed after a parabolic rise.

Opioid Deaths May Be Starting To Plateau, HHS Chief Says

The credit can go to harm reduction programs, public health and safety efforts and community organizations who have worked hard toward solutions.

Good news certainly, but not cause to disarm.  The death numbers, even if they plateau, are staggering.  70,000 deaths in 2017. Many young people, who would otherwise have many years of life, family and contributions to society left, had they not been ensnared in this terrible epidemic, are vanished.

Ensnare is another word for the day.

Here are the synonyms (also from Merriam-Webster) - catch up, enmesh (also immesh), ensnarl, entangle, entrap, mesh, net, snare, tangle,trap

I recently attended an opioid overdose conference where one of the speakers, addressing her daughter's death, called her child's journey into opioids "an innocent entry" and an "impossible exit."

Powerful and true words.  

We don’t know what the future holds.  Will a new deadlier opioid emerge or a new combination of drugs?  I don’t know.

***

Things in Hartford were very quiet early this October.  I am involved in a process tracking opioid overdoses in our service area and we witnessed a lull in the first half of the month.  Overdoses were down 50%. Driving down Park Street, the ever present users on the nod seemed to have disappeared as if taken by spaceship.  What was going on? I inquired of neighboring services, asked at the hospitals and talked to users on the street. They all reported the same things.  Overdoses are way down.

Was it a turning point or a lull?

Then things started picking up again.  The nodders were back. New brands hit the streets, as well as some oldies.  Red Star. Power Hour. Pray for Death. Fuck You. Power Ball. One Way. Calls for overdoses went out.  Naloxone vials came off the shelves.  Users had their respirations restored with some denying they had used, some vowing to never do it again, and others choosing not to say anything in scenes that can only be called commonplace.

I did ODs three days in a row.

An old man sitting on the porch, unconscious.  In another world, I would be thinking stroke, diabetes or ETOH.  His wife, who called, sits at the table and shakes her head. “Heroin,” she says.  “He’s at it again.”

We nudge him and barely get  a response to pain. His pupils are pinpoint.  His SAT is in the 80’s. He has COPD.  His ETCO2 is in the 70’s.  We give him just enough Naloxone to, with O2, get his SAT into the low 90s, his ETCO2 in the high 40s and get him to at least mumble some answers.  Instead of an empty vodka bottle, by his chair we find a torn glassine envelope. A $4 bag of heroin is cheaper than a pint of vodka on the avenue, and the effect is more pleasing.  I don’t know the relationship between the man and his wife, but I suspect it is not what it once was in their younger days and heroin offers the old man a form of escape.  Today he just caught a bag with a hotspot.  At the hospital he is alert enough to admit he sniffs a little heroin now and then.  

A young man collapses on the sidewalk and gets from bystanders both IM naloxone in his thigh and an ice filled Slurpee in his pants.  He comes around with some bagging and another 0.4 mg IV from us before he is resurrected.  The crowd of thirty or so  all praise each other and EMS for another life saved, while the young man hangs his head in shame as a woman lectures him that this had better be the last time.

The third patient has no human audience for his overdose.  No disproving wife to call 911. No bystander to fill his pants with ice.  He dies alone witnessed only by the skulls on the torn glassine envelopes by his bedside.

***

48 Hartford residents died in the first six months of 2018. 68 people died within the city limits.

Whether is it stacking bodies to the sky or just laying them on an already high ground, it is too many.

Years ago, a United States Senator, William Proxmire, used to have a saying about federal spending.  “A million dollars here and a million dollars there, and pretty soon you are talking about real money."

To paraphrase for the opioid epidemic:  A thousand bodies here and a thousand bodies there, and pretty soon you are talking about a massacre.

 

Cocaine with Fentanyl

 

(Image from InspireMalibu)

When they can’t get a hold of their local dealer, the two young men come in to Hartford from the suburbs to buy cocaine. Bart boasted to a younger friend Milton that he could get any drug he wanted on Park Street. “Well, let’s do it,” Milton said.

It is true that Bart knows where to buy drugs.  What he hasn’t told Milton is that when he used to do heroin, he met a friend named Mark who would do the buying for him. And since he got out of rehab, he has only been using percocet.  He doesn't inject anymore because his veins are hard to find because of his chubby arms.  Only Mark could hit his veins and Mark has been no where to be found, which is a good thing as Bart can handle the Percocets better than he could heroin. Bart has also never purchased cocaine in Hartford, though he knows the same guys who sell heroin have coke. Bart sticks with his boast.  “Sure, let’s do it.”

They park Milton’s car on Zion Street. They get out and start toward Park. “You sure, you know what you’re doing?” Milton asks.

“Yeah, yeah, put your hoodie up. They got cameras all over the city.”

They walk into the November wind, hoodies up, hands in pockets.

The first guy standing outside the bodega says, “Yo, what are you looking for?”

“Coke,” Bart says.

“How much you want?” the man says.

They haggle briefly on the price. Bart gives the man what he asks for. He palms the cash and gives it to the man in a handshake that moves into an awkward embrace. The man nods to a young man sitting on a nearby stoop, who saunters over and shakes with Bart, slipping him the envelope.

“I told you, yo,” Bart says to Milton when they get back in the car.

“Cool,” Milton says.

Bart looks at the bag then. It is a glassine envelope like they sell heroin in, but inside the envelope is a small ziplock bag full of white powder. “Look at all that,” he says. “I told you it cheaper in the city.”

“Let’s go to Jeanna’s,” Milton says.

There is a girl Milton knows from the magnet school who has an apartment now on Sigourney Street.

“This isn’t enough for three,” Bart says.

“She parties, but she doesn’t do drugs. She’s cool, though.”

They ride over to her place, after buying a six pack of Modelo at the corner store for Jeanna. She buzzes them in, and she gives Milton a kiss as he squeezes her bottom. They make introductions, and then with Cardi B on the sound system, Jenna fetches them a paper plate. Bart spreads the powder into four lines, and hands Milton a broken off bic pen. “No, you do the honors,” Milton says. “You’re the man.”

Bart feels really good about the compliment. He leans over and the pen in his nose and the other nostril clogged off with his thumb, he inhales a line, and then hands it to Milton. The feeling is odd. There is a rush, and it is not the typical warp speed thrill. It is good and familiar, but not right. It is powerful and warm, but not what Bart was expecting. He feels faint, and starts to give himself up to the feeling.  he looks at Miltons and sees something is wrong.

Milton falls face forward, and hits the floor hard.  The girl screams.  Shit!  

Bart checks Milton’s chest. Oh, God.  Oh God.  Milton is gurgling and he vomits. Bart rolls him on his side, and shouts call 911!  The girl is crying. “Now! Now!” he says.

***

We arrive after the police and fire department.  A young bearded boy, who looks familiar to me, sits against the door in the hallway crying, and looking scared. A police officer stands over him. “Is this the OD?” I ask.

The officer shakes his head and nods into the apartment. On the living room floor a young man lays on his back, his arms outstretched. He is very pale. A firefighter stands over him trying to assemble an ambu-bag while another firefighter attaches the hose to the oxygen tank in his blue house bag. I see a discarded vial of narcan by the boy’s head. I look at him carefully. He looks dead. “Is he breathing?”

Just then, I see his Adam's apple move with one agonal breath.

The FD starts bagging him. I attach the ETCO2.  It is 100.

“Any paraphernalia?” I ask.

“They all deny drug use.”

I see a girl crying on the coach.

“What did he use?” I ask her.

“I don’t know. I just had a beer. He just fell over and his friend told me to call 911.”

His blood pressure is good, his heart is going at 112. Pupils are pinpoint.

I go out into the hall, and ask the kid. “What did he use?”

“I can’t answer that.”

“We’re just trying to help him.”

“I, I , think I need to consult with my lawyer.”

“You’re not in trouble. He’s not under arrest, is he?”

The officer shakes his head.

The boy avoids my eyes.

I go back in the room and see the boy’s end tidal is down to 50. I give him a sternal rub, but he doesn’t respond. The ETCO2 is now in the 40’s. I tell them to stop bagging. His respiratory rate is now 16. SAT is 100. ETCO2 - 42. He is stable.

I go back outside. “Your friend is fine. He responded to narcan. What did the bag look like you bought?”

“You can tell us,” the cop says. “You’re not under arrest. Its just to help your friend.”

The boy looks uncertain.

“You are going to be in trouble if you don’t help,” the cop says.

“It was a clear bag,” the boy says. “We just bought cocaine. He wanted to do some. It was his idea.”

“Cocaine, huh,” I say. “Seems there was probably some fentanyl in it.”

“It felt like percocet,” the boy says.

“How do you know that?”

“I use prescription pain meds,” he says.

“Does you friend do pills, too?”

“No, just cocaine, and he smokes pot.  We both do, a little.” 

“Maybe because he doesn't use pills is why he went out and you didn’t. Be careful what you buy these days.”

The friend finally arouses, but he is too groggy to walk. We stair chair him down the three flights and take him to the hospital.  

“What happened,” the boy says, in the ambulance. “Was I in a car accident?”

***

This isn’t the first time someone in Hartford has bought what they thought was cocaine, but it ended up either being heroin/fentanyl or cocaine laced with heroin/fentanyl.

It is almost impossible to tell white heroin, fentanyl and cocaine apart by sight.

What happened to the boys? Did the dealer think Bart said dope instead of coke? Did he sell him coke that he had spiked with a little fentanyl? Did someone higher up the chain do the same?  Or maybe it was contamination at the drug packaging site? Did they neglect to clean the grinder and the scale they used for fentanyl before they started in with their cocaine packaging?  A little cross-contamination?

There has been a lot of speculation about this issue. Here are two good articles about it.

How Fentanyl Is Contaminating America’s Cocaine Supply

Cocaine Deaths Are Rising At An Alarming Rate, And It’s Because Of Fentanyl

A friend of mine in harm reduction thinks it is accidental contamination. He says it doesn’t make sense a dealer would add fentanyl to the cocaine, which might kill his customer if they are opioid naive.

Deliberate or intentional, these overdoses are increasing. Not just in Hartford, but across the country.  Anyone buying or using cocaine these days needs to be careful. Have naloxone available just in case.  Don't use alone.  Do just a little at a time.  Call 911 if someone overdoses.

 

Sunday, October 28, 2018

Chains

 

We’re sent to the courthouse where a marshal takes us back to a holding cell. A thin, bearded man with cuffs around his wrists and his legs chained is bent over in the bare cell, grimacing.

“Guess he got nervous about seeing the judge,” the marshal says to us, “Developed himself some back pain.”

“I’ve had back pain all day,” the man says. “And I’m not ducking anything. I’m in here for panhandling for Christ sakes! I can’t fucking sit up.”

“You didn’t tell that to the officer who brought you here?”

“He knew I had pain. I was sitting on the side of the road, holding my sign. I couldn’t even stand up. He had to help me into the god damned squad car. He brought me right here. I’ve got a warrant for failure to appear for another panhandling charge. Big bad criminal, that’s me.”

There is a term called “jailitis” that implies that prisoners are faking sickness to get out of jail, knowing they have to be brought to the hospital, and even though they know they will be returned to their cell eventually, the trip breaks up the monotony of their time. It is so common that jailors tend to lose the belief that anyone in their cells could ever really be sincere about their conditions. They call us per policy only to avoid liability should anyone truly be sick and not get care.

“I’m in terrible pain right now,” the man says to the marshal. “I’m always in pain, but not this bad. Plus in another hour, I’m going to puking and shitting myself.”

We transport the man with one hand cuffed to the stretcher railing and a police officer following us in a squad car. The prisoner tells me his tale. He is from a town in eastern Connecticut and he comes to Hartford to buy fentanyl. He says he hurt his back in a construction accident ten years ago. He went to a pain doctor who overtime increased his pain prescription to three 80 milligram oxycodones a day.

“Then one day I go in and his receptionist tells me he got arrested. No other doctor would take me. I’m on three 80 milligram oxycodones, for Christ’s sake!  What choice did I have then? Just stop taking it?” He shakes his head. “Let me tell you. You don’t ever want to go through withdrawal. I’ll do anything to avoid it.”

He is only forty-two, but he looks like he is in his late fifties. His face is hard, deeply lined. His tortured blue eyes look like he knows what it is like to be chained in a dungeon. He reminds me of the character in the old Far Side cartoons who is, in fact, always chained to a wall. The only difference is this man is real and nothing about his condition is funny. “Withdrawal -- it’s fucking hell,” he says.

Friday, October 26, 2018

Unforgiven

 

He is walking down a side street off Park when he freezes in place. He sees the slow moving black Toyota blink its lights, then he sees the station wagon. Before he can take a step to flee, he sees the barrel come out of the back window. He feels the impact against his shin and another in the hip. He dives behind the bus stop shelter as more bullets splat against the wall of the boarded up store behind him.   He scrambles up and runs into the street. He takes the orange he has in his pocket and heaves it at the car. Then he holds up a double barreled middle finger. “Fuck you! “ He shouts. “Your product sucks!”

“Five times I’ve been ambushed this week,” he explains to me that afternoon. “He hit me eight times. Hurts like a mother. Look at me, I’m covered in paint. He uses a different car for his shooters every time.  He flicks his lights to give them the signal, the bastard.”

Mickey is a homeless addict who is a fixture on Park Street. He is short and wirey and missing most of his teeth. Every six months he disappears for awhile, going to stay with his aunt in rural town in the northeastern part of the state. Invariably, I see him back on Park Street. He doesn’t want to be an addict for the rest of his life, but staying with his aunt in the country makes him stir crazy. He has nowhere to go in the town. He can’t drive, he has no friends, there are only so many chores you do around the house and only so much TV to watch. He gets the urge to call old friends, and then he fucks up and he is back on Park Street. While Park Street has heroin and he knows heroin will kill him one day (He’s already had a heart valve replaced due to endocarditis); on Park Street, Mickey is somebody. He has acquaintances. People know his name, even if one of them is trying to hit him with paintballs.

The paintball attacks started five days ago when, not able to find his normal dealer, he bought an unmarked bag off another dealer he knew.

“Four dollars” the guy told him. “It’s great. Four dollars.”

“It’s not all cut with that crazy stuff.”

“Four dollars. You’ll love it.”

He forked over his bills.

It gave him what he called a bad weed high. He felt all dark and paranoid, almost catatonic, all the while his heart was racing. He felt like crap for the rest of the day. When he tried to get his $4 back, the dealer told him to fuck off, so he invested the better part of two days telling everyone on the street, the dude’s product sucked and now no one will buy it. The dude even changed his brand, and still no takers. Mickey has a big mouth. He laughs when he tells the story. “So he’s pissed at me.”

“You have to be careful you don’t get hit in the face.”

“All the shots so far have been below the waist. That’s the code. I’m worried he’s going to get me in the nuts. I got newspaper there for padding.”

I had to admit I laughed about the comic manner of Mickey’s storytelling and the thought of a pissed off drug dealer chasing a wise-guy half-pint all over Park Street and surrounding side streets with a paintball gun. Mickey’s a tough guy, and he uses humor as a shield against the cold realities of his life. Despite his bravado, I have also seen him cry talking about all the times he’s been beaten up for fun, and I’ve seen him sick and looking like death in the waiting room of a clinic he was checking himself into in another attempt to get clean and get off the streets.

I hope Mickey is forgiven by his tormentor.  I hope the feud ends quickly.  And as painful as paintballs can be, I am grateful they are not bullets.

 

Wednesday, October 24, 2018

In Praise of Tim Phalen

 

If you ever get a chance to take a 12-lead class from Tim Phalen, Don't miss it. Tim has been teaching 12-lead classes across the country for over twenty years. I first took a class from him about that long ago. He is a great presenter with the gift of making complex concepts seem easy.

When I first took his class, he told a story about Elvis the janitor, who he and his buddies taught how to read 12 lead ECGs. Elvis would be mopping the ED floor and then peer over the shoulder of a medical resident intently studying a new ECG. “Inferior MI,” Elvis would say, and then continuing mopping. A few hours later, he would glance at another ECG the resident had just obtained. “Anterior.” And back to the mopping, He became a legend in the ED for his savant-ability to read ECGs. How did he did he do it?

Simple. Tim and his buddies taught him Big and Tall is Bad. Lower corner is inferior, The right side of the page is Anterior.

Wallah!

Phalen, of course, teaches to a level of detail far greater than Big and Tall is Bad, but if through simple concepts he can teach a medically untrained janitor to recognize a STEMI, think of how effectively he can teach a paramedic to recognize a patient with a left bundle branch block who is also having a STEMI.

I’ve bought several of Tim’s ECG books over the years, mainly to replace ones I’d lend out that got relent and never returned. His books are well done, easy to learn from, and well worth the price.

I was excited recently to learn that Tim would be presenting a 12-lead class at our service.

In EMS, we sit through so many presentations that are dull and boring. Death by PowerPoint. I’ve been guilty of it myself. Watching Phelan is watching a master. His ability to keep things simple, and to circle back with repetition so the key points sink in is masterful.

Since the audience was experienced medics, he focused on more advanced concepts rather than an introduction to 12-leads in the three hour class he gave us. The STEMI equivalents and the imposters. I had heard of Wellen’s sign, DeWinter’s T waves, Brugada Syndrome and Scarbossa before, but I understand them much better now. He also covered Left Main Equivalent/Triple Vessel Disease, post ROSC ECGs, as well as Left Ventricular Hypertrophy, Bundle Branch Blocks, Early Repolarization and Pericarditis with helpful simple tips to recognize them.

My fellow medics were all very excited afterwards, and anxious to go out and do 12-leads. The best EMS classes get you fired up about your job and Tim Phalen certainly accomplished that.

Kudos also to Mike Hooper, a name well know in this region, who has been the sales rep for Physio products since I can remember. Super nice guy. He taught us a class recently on how to use our new Life Pack 15s and accompanied Tim on his recent teaching tour of the area.

The latest edition of Tim's book with updated material  will be coming out in November and will be available on Amazon.  You can pre-order it here:

The 12-Lead ECG in Acute Coronary Syndromes 4th Edition

Friday, October 19, 2018

Obituary

 

I see Maria outside the Spanish market, squatting against the building. She is a tiny woman in her fifties who was introduced to heroin thirty years ago when she was living in New York. The father of her son used it occasionally and when he used, she was obligated to sniff some as well. It didn’t take her long to get addicted. She has grandkids, but she never sees them. Her father is still alive, but even though she misses him terribly, she doesn’t want him to see what she has become. She says she would like to quit, but she has no help. She stays here and there, and is dependent on people coming out of the market and giving her their loose change. She doesn’t beg or ask or bother people, she is just squatting there. People who know her and know what she needs hand her some change. When she gets four dollars, she walks a block and goes behind a cafe and buys from the guys in the back lot. “No Fentanyl,” she tells them. She just wants heroin, enough to keep her from being sick.

I’ve taken her to the hospital a couple times. Once when she fell and cracked a bone in her leg. A week later, she was back on the street, hobbling on a cast. Another time, over a year ago, we found her in the alley with the needle still in her jugular vein. She was breathing and we could rouse her with stimulation, but she was zoned out. She cried on the way to the hospital. She had a small bag with her. In it were clean needles and a cooker she got from the needle exchange van, along with a portable sharps container. The hospital confiscated it, and she had to go back to the needle exchange van and plead for more needles which they gave her. They have a "one used for one clean" needle policy, but can be persuaded to give more. They know people will pick up needles off the ground and use them if they have to. When I take people to the hospital now, I try to tell the staff that these clean needles they have are legally theirs and shouldn’t be summarily tossed. I had to get a doctor once to order the staff not to throw them out.

Last year I was going into the market and asked Maria if she was hungry. I had her come into the market with me.  She pointed to a sorullo in the glass display case, fried cornmeal with cheese in the middle. “Can I have something to drink, too?” She asked. She pointed to a can of Kola, which I had the woman behind the counter get as well.

The next time I saw her outside the market, I said, “You want me to buy you a sandwich or do you want two dollars?”

“Two dollars,” she said, quickly. I gave her the money and then went inside and ordered her a sorullo and a Kola, which I gave her in a small paper bag when I came back out.

“We have to put some meat on your bones,” I said.

My coworkers and I discuss how to handle the homeless. Most say they offer to buy food, but never give money. There is a guy who hangs outside Burger King named Johnny. He is in his forties, a thin hard-faced man with hair to his shoulders, who is always sitting there head down reading a paperback thriller. He also relies on people to hand him change. My old partner Jerry often invites him in to buy him a meal. When I see him, I chat with him for awhile and then give him a couple dollars and a bottle of water.  Let him decide what he wants to do with the money. (His story is he got in a bad car accident in his twenties.  His doctor gave him Percocets in increasing doses for two years and then one day just cut him off cold, saying he shouldn't be in pain anymore).

Last Thanksgiving, I brought in turkey and gave out portions to several of the regular homeless addicts I know. They were all very grateful, but I heard later from two of them that it made their stomachs upset because they were not used to eating fatty meat. I have read that when people are addicted to heroin, eating ranks low on the totem pole of desire. They eat only to have enough strength to be able to raise the money and then go get the dope they need to keep from feeling sick. If they did a study on the homeless and addicted to heroin diet, no doubt its adherents would lower their percentage of body fat. The exercise of walking all day and not eating does the trick.

My partner and I give out oranges and apples and the homeless will sometimes eat those fruits in front of us like the zombies of the walking dead eat people. Still I think if I asked do you want orange or a dollar, they would still take the dollar. The orange might satisfy their hunger, but the dollar will help them buy their next bag of heroin, and the heroin will help them feel better.

It is pouring rain this morning. A young woman named Cloey stands in the rain holding a “Homeless and Hungry” sign. I have only seen her a couple weeks so I don’t know too much about her. She has a nice smile and a girlish manner to her words. She could be a friend of my daughter.

It is still early in the morning and I haven’t stopped at the grocery yet to get a bag of oranges. I don’t even have any dollar bills in my pocket. I do have some water in the cooler, and a pocketful of change. We stop and I get out and give her a water and some change, maybe a $1.73 or some odd number like that. I ask her how she is doing, and she thanks me, but says “I am really sick this morning.” I feel bad for her. Some day when I get a chance to talk with her further I will ask her what happened? What were the turns in her life that brought here out to these streets, begging for change in the rain?*

I see her briefly that afternoon. The rain has stopped and the sun shines through the clouds and starts to bake the water off the asphalt and grass. It’s not yet humid but it soon will be. She waves as she walks by, and then she stops briefly and says. “Thank you for this morning. I’m feeling much better now. I was really not doing well. Thank you.”

“You want a water?”

I hand her a water from the cooler I keep at my feet in the front of the ambulance. She takes it and gives me a young girl’s smile, before she walks back up toward Park Street.

I have heard people say if you want to help the homeless, give money to social organizations who help the homeless instead of putting the money directly in a homeless person’s hand. It goes along with the expression, “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” This implies that the money you give to the heroin addict only buys them a few hours of not being sick and they are back to square one when the money given to the organization may eventually help lift them out of their circumstances. I don’t dispute that. I do give small donations to the Greater Hartford Harm Reduction Coalition to help them with their efforts to keep people alive until they are ready to enter recovery. But I also give money directly to the homeless. It is not a lot of money. Just spare change really. I don't consider myself a generous man.  I hang up on telephone fundraisers and don't answer the door when charities come collecting with tin cups in their hands.  I walk right by them when they stand in front of the supermarket.  I am not a Sunday church goer so I don’t put my weekly tithe in the collection plate. In a way the city I have worked in for much of my life is my church. When I give money to a homeless person, it makes me feel spiritual -- as a human being, I feel less alone in the world. I hope it makes them feel that same way. We should all feel connected.

* I get a chance to talk with her a week later.  She was born to a 14 year old mother, who gave her up at a young age because she was a heroin addict.  She is still alive, a homeless addict herself in a Western city.  Cloey tells me she tried heroin as a teenager because she wanted to know what it was about the drug that could cause her mother to care more about heroin than her own child.  "As soon as I tried it," Cloey said.  "I understood."

Obituary

 

I had three people tell me to read this obituary a woman wrote about her sister who died at thirty-two after a long struggle with addiction.

Madelyn Linsenmeir, 1988-2018

Powerful.  

While I am most moved by the first part that describes Madelyn and shows the clear love of her family for her, I am excerpting the end below because it contains a message for us as health care professionals.

If you yourself are struggling from addiction, know that every breath is a fresh start. Know that hundreds of thousands of families who have lost someone to this disease are praying and rooting for you. Know that we believe with all our hearts that you can and will make it. It is never too late.

If you are reading this with judgment, educate yourself about this disease, because that is what it is. It is not a choice or a weakness. And chances are very good that someone you know is struggling with it, and that person needs and deserves your empathy and support.

If you work in one of the many institutions through which addicts often pass — rehabs, hospitals, jails, courts — and treat them with the compassion and respect they deserve, thank you. If instead you see a junkie or thief or liar in front of you rather than a human being in need of help, consider a new profession.

We take comfort in knowing that Maddie is surrounded by light, free from the struggle that haunted her. We would have given anything for her to experience that freedom in this lifetime. Our grief over losing her is infinite. And now so is she.

 

Tuesday, October 09, 2018

Supraglottic Versus ET

 

“EMS personnel and physicians involved with protocol development for EMS systems in the United States, United Kingdom, and similar settings with limited exposure to advanced airway management should reconsider the routine use of endotracheal intubation as the first-line strategy for airway management in out-of-hospital cardiac arrest.”

This is the conclusion of an editorial in the August 28, 2018 edition of the Journal of the American Medical Association.

The editorial, “Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest,” is in response to two major new prehospital randomized, controlled airway studies published in the same edition of the journal.

In the first study, the Pragmatic Airway Resuscitation Trial (PART), researchers found initial insertion of a laryngeal tube (King-LT) in victims of cardiac arrest “was associated with a significantly greater 72-hour survival compared with a strategy of initial endotracheal intubation.” The authors found that a King LT Airway outperformed the endotracheal intubation in every category in which they compared, including a 2.7% better increase in survival to hospital discharge, which would translate into 10,000 additional lives saved nationwide.

The second study, AIRWAYS-2, did not find a statistical difference between using a supraglottic airway (igel) and endotracheal intubation. These were both high quality studies conducted at many sites in the United States (PART) and Great Britain (AIRWAYS-2).

The Pragmatic Airway Resuscitation Study (PART) enrolled over 3000 patients and was conducted by 27 different EMS services in 5 metropolitan areas over the course of two years.

You can read the studies and editorial here.

Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome The AIRWAYS-2 Randomized Clinical Trial

JEMS has an analysis of the study here:

ETI vs. SGA: The Verdict Is In

There have been many other analyses of the studies on medical sites.

The Great Prehospital Airway Debate

AIRWAYS-2

Why are we still intubating, when there is no evidence of benefit and we refuse to practice this “skill”?

EM Nerd-The Case of the Needless Imperative

What does this mean?

Here in Connecticut, we no longer consider the endotracheal tube as the gold standard for airway management. Supraglottic airways can be either the primary or backup airway based on the circumstances of each call.

Additionally, ET is limited to three attempts.

Before we went to statewide protocols, our regional guidelines limited ET attempts to two by the first medic, and one additional attempt if another medic is present and wants to try.

That works for me.

I am not ready to give up on ET intubation. It remains my preferred method, but I do not hesitate to drop a combitube from the get go if I am presented with a patient who I suspect based on their anatomy or where they lay, will be a difficult tube. I once immediately dropped on combitube in an obese patient in a hospital bed that was shoved into the corner of a room in a horder’s house. Fifteen seconds later, I had an airway. If I had gone for an ET, I wouldn’t have even had my ET roll unzipped, and the tube and stylet and syringe unwrapped from their sterile packaging, much less having to move the bed and patient and all the crap in the house that would interfere with that.

If a medical director told me that based on his reading of the literature and his worry that the risk of ET intubation in the hands of unskilled medics was too great and that we should remove ET intubation altogether, I would understand and would have a hard time protesting too loud.

Remember: The important airway goals are safely securing the airway in a timely fashion, avoiding interruptions in chest compressions, and limiting attempts. In cardiac arrest, the only two interventions proven to improve mortality are quality chest compressions and timely defibrillation.

Friday, September 14, 2018

Connecticut Overdose Death Numbers

 The opioid overdose epidemic continues to rage in Connecticut, although numbers again show the carnage may be plateauing.

The Connecticut Medical Examiner's Office just released the overdose death numbers for the first six months of 2018.

Connecticut Medical Examiner's Statistics

 515 people died in contrast to 500 and 538 in the two previous six month periods.

The numbers continue to show the rise of fentanyl as the cause behind the overdose deaths,

Source: Ct. Medical Examiner's Office numbers.  Graphs by Canning.

Connecticut Overdose Deaths Plateau

 

Monday, September 10, 2018

A Walk in the Park

 

A walk in the park to stretch the legs while on post. The medic walks past a row of port o-potties from a weekend event.

One port-o-potty is not fully closed.  A sneaker blocks the door door. On second glance the sneaker is attached to a foot.

Open the door and an unresponsive man tumbles out. A syringe and empty heroin bags lay on the ground. The man is blue and breathes only on stimulation. One shake, one breath.

The medic radios his partner who drives the ambulance across the sidewalk to the scene and bring overs the house bag. No more one shake, one breath. A proper ambu-bag is applied while the naloxone is readied.

A man sprint frantically across the park directly at EMS scene.

The running man stops and stands a few feet away, looking hard at the overdose victim, whose face is covered by a mask.

The medic lifts the mask briefly to let the man look. “You know this guy?” the medic asks.

“No,” he shakes his head. “I thought it was Doug.”

A moment later, another porto-potty door opens and a man stumbles out. He looks dazed and confused..

“Doug! Doug!” The other man shouts. “You’re all right. I thought this dude was you.”

Doug looks at us still bagging the patient. “Fuck,” he says.

With the naloxone in his system, the victim is starting to breathe better on his own. His ETCO2 has dropped from 100 to 48.

During the commotion a large flatbed truck has backed down the sidewalk. The crane on the back lifts the last port-o-potty in the row up in the air and places it on the back. 

We lift our patient up on the stretcher, and wheel him toward the ambulance.

He opens his eyes now and looks about. “Oh, Christ!” he swears. "You guy's Narcaned me, didn't you?"

“Believe it or not,” the medic says, watching yet another port o-potty being raised into the air. “It’s your lucky day.” 

Saturday, September 08, 2018

The Opioid Chapters

 Check out this web site to read about eleven people affected by the opioid crisis, including a paramedic who injured his back on the job.

The Opioid Chapters

Thursday, September 06, 2018

Fentanyl: The Real Deal

 Misinformation and inconsistent recommendations  regarding fentanyl have resulted in confusion in the first responder community.

- Fentanyl Safety Recommendations for First Responders (Revised) from the Office of National Drug Control Policy.

It seems every week responders are getting exposed to Fentanyl, being rushed to the hospital, with many getting Narcan, all often without exhibiting any symptoms or symptoms no worse than lightheadedness and tingling hands.  

OFFICERS HOSPITALIZED AFTER BECOMING DIZZY AND FEELING ‘A TINGLING SENSATION’ AT SCENE OF FATAL FENTANYL OVERDOSE

Cops left dizzy and numb after exposure to mysterious substance during NC drug search

I have been told at scenes to be careful that just touching a speck of powder could kill me.

No, I say, that's not true.

I have been writing about his for over a year now, and fortunately the The American College of Medical Toxicology and the American Academy of Clinical Toxicology, and even the first edition of the above document, helped correct much of the early damage done by the DEA's first document, Fentanyl: A Briefing Guide for First Responders.

Fentanyl: A Briefing Guide for First Responders

Fentanyl Skin Exposure: An MD’s View

Fentanyl Exposure: The Toxicologist’s Take

Controversies and Carfentanil

Nocebo Effect

Falsehood Flies

Fentanyl Safety

To rectify this confusion, the government has released a new YouTube video called Fentanyl: The Real Deal.

Fentanyl: The Real Deal

One scene tells it all.

A police office gets some powder on his hands and screams "I got some on my hands!" and then gets all woozy.

His partner tells him, "Wash your hands.  You'll be okay."

And he is fine.

Here's the bottom line:

Touching Fentanyl will not kill you.

If you get it on your hands, don't touch your nose or eyes.

Wash your hands with soap.

Wear gloves.  If there is powder in the air, wear a mask and eye protection.

You do not need to get narcan sprayed up your nose just because you were exposed.

Only give naloxone to someone who is hypoventilating or with true signs of the opioid toxidrome syndrome.

People who are hyperventilating do not need naloxone.

Follow your treatment protocols.

 

Friday, August 17, 2018

Safe Injection Sites

 

I wrote an op-ed this month that was published by the Hartford Courant.

Insight: I See What Heroin Does. Let People Shoot Up Safely

Included was a checklist:

5 Things to Know About Heroin Addiction

I read an article a few days later that said that when called an "overdose prevention site," as opposed to a "safe injection site" people were much more likely to support the concept.

Support increases when opioid 'safe consumption sites' called 'overdose prevention sites'

For me the bottom line is harm reduction.  We may not be able to stop people from using heroin, we can at least mitigate some of the harmful effects of it.  Safe Injection Sites/Overdose Prevention Sites have been proven to keep people alive and get some of them into treatment.  We can help prevent the spread of disease and keep our streets cleaner.

 

Thursday, July 19, 2018

Epinephrine in Cardiac Arrest

 

The use of epinephrine in prehospital cardiac arrest showed no difference versus placebo in determining favorable neurological outcome according to a long awaited randomized controlled study published yesterday (July 18, 2018) in the New England Medical Journal.

The trial showed epinephrine produced a higher rate of survival at 30 days than placebo, but that was accompanied by almost twice the rate of severe neurological impairment.

Over 8,000 patients were enrolled in the randomized double-blind trial conducted in the United Kingdom between December of 2014 and October 2017.

The thirty day survival rate was 3.2% in the epinephrine group versus 2.4% in the placebo group. At hospital discharge 31% of the epinephrine survivors had severe neurological impairment versus 17.8% in the placebo group.

Paramedics needed to treat 112 patients with epinephrine in order to produce one extra survivor and that survivor was much more likely to have a poor neurological outcome than a placebo survivor.

The authors of an accompanying editorial speculate that while epinephrine may increase return of spontaneous circulation, it may also "result in long-term organ dysfunction or hypoperfusion of the heart and brain."

You can read the study and accompanying editorial at these links:

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Testing Epinephrine for Out-of-Hospital Cardiac Arrest

 

Will this result change AHA ACLS guidelines?

We will have to wait and see. The AHA has been very reluctant in the past to make changes in the ACLS cardiac arrest epinephrine recommendation despite multiple trials showing no benefit or possible harm. Perhaps they will further temper their current recommendation.

Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest (Class IIb, LOE B-R).

What is next?

Look for studies using a decreased dose of epinephrine or studies targeting specific rhythms.  I have always thought it odd that we use the same 1 mg dose of epinephrine for an 80 year old 100 pound woman with a cardiac history who collapsed having an MI and for the thirty-nine year old 250 pound male with an opioid overdose.

In the meantime, what does this study mean for front line paramedics?

Focus on good CPR and timely defibrillation.  

Thursday, July 05, 2018

Veins

 

Kelly is as dispirited as I have seen her. “My veins are shot,” she says. “I can’t even get high.” IV users use 1 cc syringes which have a very small needle they only need to slip inside the vein. When they pull back and get blood they know they are in. They push the plunger slowly, sending the heroin directly into their vein and right into their circulation where quickly delivers its powerful payload to the brain. This is a faster and stronger route than swallowing a pill or inhaling the powder in through the nose. If however, the needle in not anchored in the vein, the drug goes into the tissue where it can cause damage and necrosis. The user still gets an effect, but it is less strong and comes at a price in damage to the tissues.

Kelly has shown me her veins before and they are challenging. I fancy myself an expert at inserting intravenous lines. I may be an average medic in some skills, but I am really good at IVs. I have been doing IVs for twenty five years on all types and ages and races of people.
There is a difference between doing an IV as a paramedic and inserting a hypodermic needle as a drug user. A paramedic has to insert the needle into the vein, and then they have to slide a catheter over the needle and anchor it in the vein. 

One key is to find the best vein. The easiest vein is the AC in the crock of the elbow, but when this is not available, I look for the vein along the wrist or one of the many hand or firearm veins. Sometimes, I use a small needle. A 24 gauge is the smallest we use. The higher the number, the smaller the gauge. IV users typically use and go under the wrists or high up on the bicep for a superficial vein. I didn’t used to, but now I need to put on my reading glasses to see the smallest veins. I enjoy getting compliments from intravenous drug users who are my patients when I get IVs in after they tell me it is impossible. “Damn, you are good,” a woman says, and sends me a smile that makes my job worthwhile.

I don’t always use the arm. Sometimes I use the lower extremities. It is not an ideal place, but when an IV is needed, it will work. In extremis, I may also use the jugular vein in the neck. It is a large vein, but because it is deep, it requires a strong but sure touch to anchor the needle and not pierce the vein. Another difference between me and IV user is I get to practice on an endless variety of patients. An IV user is limited to their own body and to veins that they may hit too often. Some users -mechanics- may earn extra pay or free dope for injecting others. I think in another life, I would be good at this.

As part of my harm reduction efforts, I tell users how to inject safely. Rotate your veins I tell them. Clean them thoroughly before using. Ideally, with soap and water, but in a pinch an alcohol wipe will be better than nothing. Always use a fresh needle. Reusing a needle will blunt the needle and cause it to damage the vein. Never try to sharpen a used needle. Know where to get clean needles. I tell them where the needle exchange van is located. If they have money, they can also buy 10 clean needles for $3.99 at most pharmacies. Some bodegas will sell needles for $1-2. Sometimes other users who have gotten extra needles, by picking up dirty needles off the ground and exchanging them, will sell their extras for $1.  

I don't know how many of them follow my advice or let my advice get in the way of getting their next fix if they lack the soap and water, the clean needle or a dormant vein.  Users got to use, they say.

“Have you thought of trying your legs,” I say to Kelly. I ask this more to gage her reaction than to offer sage advice.

“No way, I’m not doing that. That’s bad for you. You can fuck your legs up.”

I am fascinated in her response. I am tempted to say you have no compunction about injecting a deadly drug cut with who knows what chemicals, but you don’t want to inject your legs. The legs veins are more likely to get infected and create clots that travel to your heart or brain or simply get stuck in your legs and cause swelling and tissue damage. But if your arms are shot, and you want to keep using IV, which as I have mentioned is the best bang for the rare buck, the legs are the next best alternative. The feet, the groin and the neck are all far more dangerous.

“I don’t get it,” I finally say to her, unable to hold it in.  “You’re putting heroin and god knows what chemicals it is mixed with in your body. You get a bad batch and you can easily overdose and die, but you won’t even consider, shooting up in your legs, even though you are desperate for a fresh vein.”

“No, it’s bad for you,” she says, completely without irony.

There are a lot of users limping along Park Street with abscesses in their feet.  Maybe she is feeling she needs to get around to get up her $4 to get her dope.  She isn't ready for that yet.

***

We are called for a woman hemorrhaging on the side of the road. We arrive to find her sitting against a fence. I recognize her as a heroin user I have seen on Park Street. She is sitting in a lake of blood. Her skin is cool, clammy and diaphoretic. Gloved up, we get her quickly on the stretcher and on the way to the hospital. Her pressure is 70/40. Her heart rate 135. She is in shock from blood loss, but we are having a hard time determining where it is coming from. Not her vagina or rectum. When we press against her abdomen on the right side, she screams in pain. Her lower right abdomen is hard and rigid. When I press, I see a spray of red blood come from a tiny hole in her groin.

She is an IV heroin user and she admits she shot up in her groin, trying to hit the femoral vein. The problem with injecting in the groin is it is a blind insertion; you can hit a nerve, go into tissue or puncture the femoral artery. I am guessing she either hit the artery and it is now bleeding into her, or continued use of the groin caused an abscess that ate into the wall of the artery. In either case, she is in shock from blood loss. We hold pressure on her groin and race her to the hospital, calling a medical alert, and we go right past triage to a resuscitation room, where a gowned team goes to work on her. She is up in the OR before we leave the hospital.

***

I think about Kelly and wonder what she will do. Her arm veins are shot. She works hard for her 4 dollars and if she can’t hit a vein, she isn’t getting $4 worth of hit out of her dope. And it’s not that she needs to hit the vein just once. Minimum four times a day she has to shoot up. Four times a day, every day for the rest of her life or at least until she decides to go clean. What must go through her mind as she searches for a vein? At one time did she balk at injecting in the first place? And what was it that caused her to finally crumble through that barrier?

I ask her about the first time she injected drugs and she says she was with her boyfriend Tom and two friends. They scored some Vicodin, but not having enough to go around, he crumbled it into power, squirted some saline into a spoon, and stirred it down to solution which he loaded into a syringe. He hit her first vein. Then they went ice-skating. In the winter time in Bushnell Park, the city erects a skating rink for residents of the city. You don’t need money to rent the skates they have. She tells me about skating on the ice in the park high on IV Vicodin. She describes it as if she were in a snow globe floating through the blue and white sky.

I think about the girl who punctured her femoral vein and nearly bled to death on a Hartford street. What was it like for her the first time she injected? How many years did she inject before she killed off her arm veins? Her leg veins? The veins between her toes? When did she first inject in her groin? What will happen to her when she gets out of the hospital? Will they get her into rehab? How many times has she been before? Does she believe she may be able to one day break free? Or is hope no longer a word she knows?

When the time comes for Kelly and for this other woman to die will they will be alone in misery and pain? Or will they ascend into the sky peaceful like snow globes in the clouded hands of their god, their days of suffering on earth vanished?

Saturday, June 23, 2018

Pulmonary Edema in Opioid Overdose

 

She finds him in the bathroom at seven in the morning and knows immediately he is using heroin again. Three weeks ago, they moved east from Seattle. She had a job offer and it also represented a chance to get him away from his junky friends. After three times in rehab, she didn’t think she could go through it with him again so she was thrilled when he agreed to move with her. They got a nice loft downtown, with plenty of light. It was close to her job, and from across the street, he could get a city bus to any job in the area he could find. If was convenient to many things – a minor league ballpark, movie theatres, riverside park with running trails, a health club within blocks. He was always in good shape, but he particularly worked out hard when he was staying clean. Her new job was going to keep her busy, but there were plenty of restaurants they could go to at night, along with a comedy club and local brewpub. They’d make friends, and in time, if he started working and got a steady position, they could get up a down payment and move into the suburbs, start a family. Life had potential.

Now it seems like it is all back to where it was. She doesn’t even want to know where he got it or what drove him to it. She shakes him –hard and he wakes up and looks at her with a heart-breaking pathetic look that breaks her heart, more to see what it has done to him than any sense of betrayal to her. She knows how hard it is. Her brother, his best friend, died of an OD. She thought maybe if she couldn’t save her brother, she might be able to save him.

He is breathing well enough that she doesn’t call 911. She wishes for a moment she had gotten Narcan, but thinks that might have shown bad faith in him. She watches him and positions him so he won’t close off his airway. He mumbles he is sorry. She tells him she has to go to work. They can talk tonight. She kisses him on the forehead. “It’ll be allright,” she says. “We’ll make a plan tonight.”

“It was just one time,” he says. “I’m sorry. I fucked up.”

“I know.”

Still she checks the bedroom, looks in his jacket pockets, and in the bureau.  She finds nothing. It was just one time, she tells herself.

He is still on the couch when she comes back at lunchtime to check on him. She can hear him snoring, but his breathing sounds raspy. She shakes him and he looks at her, but his face has a bluish tinge and there is pink froth on his shirt and on the couch pillows. She picks up the phone and dials 911.

***

EMS arrives, and because the man can be stimulated they don’t immediately take out their Naloxone.  He is breathing and even capable of some words, but they don’t like the man’s color. His SAT is in the 70’s. His ETCO2 is 69. They put him on a nonbreather and listen to his lungs. Rales.
With the nonrebreather, they get his SAT up to 90%. Since it is likely noncardiogenic pulmonary edema, they hold off on the nitro.  He isn't alert enough for CPAP, so they given him 0.1 mg Naloxone IV and then a second 0.1 mg.  He is more alert and can take the CPAP.  His SAT remains on the 90% line.  In the ED, he is switched to Bipap. He is admitted to the ICU, where he gradually shows improvement. He is discharged home two days later. On the advice of the paramedics, his girlfriend now has Naloxone in the medicine cabinet.  While his lungs have recovered from their damage, his fight against opioids will likely continue for the rest of his life.

***

Pulmonary Edema is a known, but rare side effect of opioid overdose that can occur independently in opioid overdose or may be exacerbated by naloxone administration.

There is an excellent case study and discussion in the January 7, 2018 article that appears on the Emergency Physicians Monthly web site.

Dyspnea After a Heroin Overdose

Additionally there is another fine article published on September 1, 2017 in Fire Engineering Weekly.

Pulmonary Edema Following Opioid Overdose

While I recommend reading these articles, as well as some of the other journal articles they reference, here are some key points about pulmonary edema and opioid overdose:

It was first documented in 1880 by the famed physician William Osler.

No one is really sure what causes it, but some of the theories revolve around lungs damaged by hypoxia or by the pressure of trying to breath against a closed glottis, resulting in damaged leaky capillaries. It may also be caused or exacerbated by increased sympathetic response.
The prevalence of pulmonary edema in opioid overdose is estimated between 0.8 and 2.4%.

One study found that 100% of overdose fatalities were found on autopsy to have had pulmonary edema.

Deceased opioid overdose patients often present with a foam cone on their mouths typical of death from pulmonary edema. I have seen this on several occasions.

Pulmonary edema can develop up to an hour after a patient has been revived.

There seems to be some dispute over whether or not nitro is of use. One article says it is not because the pulmonary edema is not due to fluid overload. The other suggests it is effective.

Rapid administration of naloxone may worsen the edema by increasing the body’s sympathetic response.

Pulmonary edema in opioid overdose is generally classified as noncardiogenic pulmonary edema, but it can coexist with cardiogenic pulmonary edema.

Noncardiogenic pulmonary edema can development immediately after reversal with naloxone or it can develop up to four hours later.

The takeaway for EMS is to observe overdose patients for shortness of breath and hypoxia post resuscitation. A patient revived with naloxone may be alert and oriented, but if their SAT remains low, they may be in pulmonary edema or at risk for developing pulmonary edema.

Monday, May 21, 2018

Slipping Out

Image result for pray for death heroin

The man is trembling, sitting on the bed in the spare motel room down by the highway. Sometimes, these rooms are filled with the patient’s worldly belongings, but this room seems to only have the bed, a dresser, a chair and the TV. The man is in his late fifties, a portly man with white hair and liver spots on his hands. The Spanish woman in the room with him is of an indeterminate age. She wears a pink tank top and grey yoga pants with flip flops, even though it is cold and blustery out. She is the one who called. When I say she is of indeterminate age, I mean she could be anywhere from 30-50. It appears she is missing a fair number of teeth and her arms lack the tone of a younger woman. While he talks to us, she walks behind him and mimics a man shooting heroin. He says he is a diabetic and hasn't eaten or taken his insulin for a couple days. He says he got robbed last night and has no money. He is going to have some funds transferred up to him tomorrow. We check his sugar and it is 485. The normal range is 80-120. 485 is in the danger zone. If he doesn't take insulin soon, he could develop diabetic ketoacidosis and go into a coma. He wants to refuse, but we keep trying to persuade him to go. "No, no, I'm fine," he says.  "I'll get some insulin tomorrow. I'm fine, really."

He doesn't look fine. “Listen, I say. "Look around this room. Do you want to die in this room? You have a couple hours and then your mind is going to get really fuzzy. You may fall asleep. In your sleep you'll lapse into a coma and we'll be here in the morning except you'll be long gone, only your body will be here. If the nice lady here is with you, she may notice you are awfully cold, and we wouldn't her to have to go through that would we?"

"You gotta go honey. I'll pay for your insulin," the woman says.  "We have to take care of you."

His eyes blink and he looks from side to side.   "Okay," he says, "I'll go."

Outside the room as we walk him to the stretcher, the woman tugs my sleeve and says something about his name. I take out a pen and pad and am prepared for her to tell me to his name and date of birth. "No, no,” she says. "I need to know what his name is.  I just met him yesterday. They won't let me see him at the hospital unless I know his name."

Okay then.; I get his name for her.; She thanks me and says she'll be down in a little while. She sticks her head in the back of the ambulance before we shut the door and says, "Tell them, I'm your granddaughter."

Granddaughter, I am thinking, with the miles on her face she could easily have been his wife.

On the way to the hospital, I put in an IV line and start running in fluid. He finally admits to me that he did 20 bags of heroin last night. He says his wife threw him out of his home and he has been living in the hotel for the last week. I asked him how he got robbed, but he doesn't want to talk about it. I tell him he needs to have narcan with him if he is going to use heroin. I explain where he can get it. I give the whole rap about not using alone and doing tester shots.

When we get him in his ED room, he is very thankful to us. He makes eye contact as he shakes our hands.  I can tell he is worried about his physical shape.

"They'll take good care of you here," I say.

At the triage desk, I tell nurse the story. I think about leaving out the part about the heroin, but I don't.

"I thought he was in alcohol withdrawal at first," I say, “but he denied it. Of course, he also denied drug use, but then copped to doing 20 bags last night."

"Winner," she says, while typing her notes in the computer, all the while on hold with the ICU about a patient she is trying to get transferred up there.

The next Sunday I am working with a different EMT as my partner is out. We are talking about the heroin epidemic and he tells me he did a presumption at the same motel by the highway on Saturday afternoon. Late 50ish man, just released from the hospital. Cops found a syringe and were treating it like a crime scene. They didn't find any heroin bags -- they said it looked like the room aside from the syringe which they found under the bed, had been cleaned before they got there. The man's wallet was empty. I queried about the room and the patient and it was the same man.

My partner mentions the patient was in an odd position. Found on the ground in a praying position against the bed.

I tell him that this actually is a common position for opioid overdose deaths to be found in.

A couple years back I did a call that really disturbed me. At eleven in the morning at a motel in town, a maid finds the door unlocked and goes in the room and screams. We arrive to find a naked man on the floor, his butt up in the air facing us. He is riggored cold, resting on all fours, stiff as can be, his head turned to the side.

On the table by the bed stand is a mobile phone that is vibrating. I look at it. Full of messages. "Honey are you okay? Honey when are you coming home? Is everything alright. I am worried."

My partners and I discuss our theories of how he may have died. Based on other evidence in the room, we speculate that he might have been having anal sex when he either suffocated or his neck snapped. We guess his partner at some point noticed he was dead and fled the scene without calling anyone; I run my six second strip of asystole. Presume him dead.

I kept expecting to see a report of the murder in the paper but there was nothing. The security footage from the hotel ought to have captured who was there with him. How could anyone leave another human being like that? I read nothing in the papers.

Several years later, I am attending a seminar on fentanyl and I find myself looking at a slide of a dead man's bottom up in the air.

The very same man.

I learn that he died of an opioid overdose. And that this praying frog position is a common one when people collapse from opioid overdose. We are shown eight more photos of dead people in similar positions, all are opioid deaths.

I try to picture now the man we took to the hospital with the high blood sugar. He gets his insulin, gets a wire transfer from his bank, and goes back to the hotel with the woman of indeterminate age. Either she or he buys the heroin. A half a stack. Party time. They shoot up, the only problem is the bags of heroin are not heroin, but fentanyl; One of the bags contains a hotspot, a clump of fentanyl. He injects and a moment later his breathing slowing, he goes dark and slowly slumps forward to his knees, his arms out before him.

When his friend awakes from her prolonged nod, she sees him there. She gives him a little shake, but he is already gone. She knows this because this is not the first man she has been with who has had heroin issues. She carefully takes the remaining bags of heroin, any paraphernalia, and then slips his wallet out of his pocket, takes the remaining green and puts the wallet back. She lets herself out into the night.

I wonder if she remembers his name.

I wonder how many other people are out there who have been in similar situations, finding; a companion dead, and then robbing them and slipping out the door.

It is a brutal world.