Tidying Up

 

Twenty years ago when I was looking to buy my first house, my realtor didn’t understand why I did not like the home she was showing me that seemed to meet all my specifications: price, location, size. She did not understand that just two months before I had worked a cardiac arrest there. I could still see and smell the man and all his bodily fluids in the cluttered living room where he collapsed. If I bought that house I would have to live with his ghost. Not for me.

Home hunting is hard when you are in EMS. You walk in thinking as I always think when I enter a home, how am I going to get the patient out of here? A stretcher will never fit in that bedroom. Spiral staircase, forget it. Even if you didn’t do a cardiac arrest in particular houses, you did arrests or memorable calls in houses with the same design. You remember the mother screaming in the bedroom. You see patients wedged between the toilet and the sink. Blood drips down the stairs.  You see all the crap that was in your way that you had to move to get the patient out to the ambulance.

I ended up buying a newer house that was empty with freshly laid carpets and big windows that let in the sun.

Today when I go into houses, I am depressed by hoarders, not just the ceiling to the floor appear on TV show kind, any kind of clutter. It bums me out seriously.  Dark apartments with dust particles visible in the air and rooms with dirty carpets and boxes of crap and untidy overflowing shelves -- it weakens me.  Maybe it is because my own empty house is now more cluttered than I would like. We can only fit one car in our two car garage there is so much stuff in it. Of course I no longer live alone. I share my house with my wife and three daughters, and all their accumulated and still accumulating possessions.

The sun bothers them.  Every time I come in the living room I open the shades. Let some light in here. When I am old, I want to live in a spare space with lots of light so when the angels (or the devil) comes for me, I will ready to go. Leave nothing behind but a few heirlooms for the kids and some money in the bank to help them make their own way without me.

I am, hopefully, many years away from that day, but I don’t want to be caught off guard. I want things tidy.

I went to a hoarder's house once. The neighbor had noticed newspapers piling up at the door and mail overflowing the box. We had to break in. This was a major hoarder. The house had newspapers stacked to the ceiling making rows in what were once big spacious rooms with high ceilings. We went all through the house wandering through the maze until at last I found her. A stack of papers and boxes had collapsed and her legs stuck out from underneath them like the wicked witch’s legs stick out from under that tornado blown house that landed on her in the Wizard of Oz.

I did another presumption recently where the room was dank and filled with boxes. The man sat dead in his chair by the window, the curtain pulled just enough so he could look out. A neighbor in fact had noticed his face in the window, unmoving, mouth open, not responding to the neighbor's frantic raps on the pane.

I need to sort through my stuff. I have boxes of books, and records and VHS tapes in the garage, but I will buy the book, music or movie again digitally with the tap of a button before I will go down to the garage to look for what I know I already own.

There is a new show on Netflix called Tidying Up. A young Japanese woman helps people declutter their homes.  Marie Kondo is the author of the book The Life-Changing Magic of Tidying Up: The Japanese Art of Decluttering and Organizing that spawned the series. I thought about buying a hard copy of the book, but instead bought it electronically on my Kindle. This weekend, I am ready to put her plan into action.

She advises starting with your clothes. You take every item of clothing you own and put it in a pile in one place, and then you go through it. Rather than deciding what to throw away, you decide what to keep. You hold each item and ask yourself if it sparks joy in you. If it does, you keep it. If it doesn’t you thank it for its faithful service, and then put it in the throw or giveaway pile. I have uniforms from past EMS services I worked for. I will never wear them again. I don’t need them to remind me of the old days.  A ti-dye tee-shirt  made by my daughter with my name on it and a smiling sun stays.  An old torn Bruce Springsteen concert tee-shirt from 1984 goes, after being thanked for years of service.

Next you do your papers. She advises you throw them all away except for those that you are required to keep (wills, birth certificates, tax returns etc.) and those that need attending (bills, correspondence). I will keep my recent CME certificates, which I am required to keep for three years, but I will throw out my handouts from classes taken decades ago, as well as all those old ECG strips I kept. Seen one v-fib, see them all. I don’t need them to remember what it felt like to shock all those people with sick, and often dying hearts.  For those rare few, I don't need the strip of the resulting sinus rhythm to remember the feel of the pulse beneath my fingers or the warmth with which their family hugged me when we later met.

When it comes to books, Marie Kondo says you shouldn’t own more than 30. A book lover, I might dispute that, but the over one thousand I own are mainly in boxes, and the ones on shelves, I rarely take down. Better me sort them now than a grandchild have to haul them off to a tag sale. I will keep a select few (The Iliad and The Odyssey, Moby Dick, The Great Gatsby and The Old Man and The Sea) as well as a box of my books (Paramedic and Rescue 471) to give out from time to time because that brings me joy.

You work your way through everything you own, finishing with the personal mementos and sentimental objects.  I will keep a wooden carved Don Quixote, a small brass Bengal tiger given me by my father when I was five, and a single baseball card of Tony Conigilaro, my childhood hero.  

The principle around all of this is stuff takes up space and energy. If you are going to have possessions you should be surrounded only by what brings you joy. I can have a garage filled with boxes or I can have space where my eleven-year-old daughter and I can dribble basketballs on cold snowy nights, working on our crossovers to see who's is better (hers).

I can’t wait to get started.

When the day comes when the medic calls the time on me, I want him to think what a beautiful clean well-lit room this old gentleman passed away in, the morning sun on his face. And I want him to look at my spare surroundings and see only the things that brought me joy (pictures of my family on the wall), the Grateful Dead’s “Ripple” playing on my Amazon Echo, and to think what a life well lived. And as I journey up toward heaven (again, hopefully as I have tried to be kind), I want to look down and feel I have left a good impression and not a cluttered mess.

 

 

Beautiful Boy: The Movie

 

Beautiful Boy, a father’s story of his son’s drug addiction, is now streaming on Amazon Prime. The movie, based on the real life stories of David and Nic Sheff, a father who witnesses his son's addiction to methamphetamine and heroin, is forced to make artistic plot choices.

I wondered how the movie director was going to handle the son’s seemingly endless relapses chronicled in the book. A typical Hollywood story has the hero slay the monster and then when everyone thinks the monster is dead, the monster comes back to life and the hero must slay it again after coming perilously close to death yet again. The problem with the real life plot of addiction is that one relapse is rare. In the book, the young man had more than I could easily count. He had so many, I felt like flipping the pages to get to the end and some resolution. Enough already! I get it!

In the movie, the director makes the artistic choice of stopping the movie after the second relapse. The father’s love for his son is apparent. The son’s helplessness in the grips of addiction is vivid. The credits roll with the coda: ”Through an incredible amount of hard work and support, Nick has been sober for 8 years. One day at a time.”

Had they followed the book and the real story, people would have likely left the theater. Movie directors are allowed license as long as they hit at the truth, which in this case, the movie does. Drug addiction is a horrible disease (not a character flaw) that can strike anyone. In the Sheff's case, Nic has an undiagnosed depression and bipolar disorder. When he tries drugs, they medicate his disease and for the first time he feels normal and whole -- a common narrative for many who become addicted in this way. Of course eventually the addiction makes him feel anything but normal.

Even with a shrunken narrative, drug addiction doesn’t make an easy movie to watch.

One reviewer, Jeffrey Anderson of Common Sense Media, said of the movie, “Lots of anguish in heavy, repetitive drug-addiction drama.”

This is not a popcorn on a Saturday night movie. It does serve as documentation of an epidemic that is gripping our country and tearing families apart, or in some case, pulling them together.

Families who have experienced addition will watch this movie and feel less alone. That is no small thing.

Here is an excellent analysis of the movie by a woman who experienced a similar situation with her family.

‘Beautiful Boy’ Is A Cathartic Gift For Families Like Mine

It is streaming free on Amazon Prime.

Calm

 

When I first became an EMT, a friend asked me why I liked the job so much. When I come through the door, people look at me like I am an angel, I said. What is it like driving lights and sirens? Another friend asked. Awesome -- I feel all powerful. I hit wail and the cars part for me like the red sea parting for Moses.

If you asked me then if there was anything wrong with what I described, I would have been seriously puzzled by the question. I didn't quite understand the true nature of the work.

When I became a paramedic I quickly learned to be a circus ringmaster, barking orders to partners, other first responders and even bystanders. All eyes were on me as I orchestrated getting vitals signs, med lists, moving furniture, putting on oxygen, getting an IV, delivering medicine, extricating the patients, even determining who could ride with us to the hospital. Eventually I brought that same leader of the band approach to running cardiac arrest (compressions, shocks, IV access, drugs, intubation, post-ROSC 12-lead, dopamine to support blood pressure, all seamlessly timed. I felt like a rock star. Driving home, I would go over in my head how well the calls went, how impressed people must be with me. Even if a call wasn’t critical, I still strode in like I owned the world. I bantered with the other responders while making my way to the patient. How’s the wife and kids? How about that car accident yesterday? Hope the Sox win tonight. I was a big city medic. Living the dream, as they say nowadays.

Of course, over time that changed. Work the streets long enough and you can't help but see the job for what it truly is. It isn’t a TV show. It is not a play in which you are the star. It is just a system for getting sick and injured people to the hospital in the safest, calmest, kindest way possible.

My old teacher Judy Moore used to say the emergency ends when you arrive. It took me awhile to understand what she meant. But I learned. When you come through the doors, you don’t bring the cameras in with you. The patient should be the center of attention, not the paramedic. Don’t suck up all the energy in the room. Cut the theatrics, the commotion, and the self-importance. Converse with the patient. Reassure them. Be professional. Do what needs to be done without fanfare.

I see my old self in a few younger providers, but I don’t say anything. They will learn. Even if they came first for the adventure and the lights and sirens as I did, if they stay long enough, they will stay for the human contact.

I remember when I was a young EMT at a car accident, doing my best to seize control. An older medic arrived in the second ambulance, and without saying a word, smiled wryly and somehow managed to make sereneness out of my chaos.

You don’t need a cape to do this job. Drive carefully, speak softly, act calmly, be competent, be kind. Be a paramedic.

Dancer

  

I first picked Veronica up on Hungerford Street one afternoon two years ago. We had been called for an unresponsive, but instead, we found a small woman with a club foot staggering along the street.  She was half on the nod and covered with leaves. I asked her if she was okay, as we walked up.  She just mumbled, and tried to keep walking. We stood in front of her and at twice her size, it became hard for her to ignore us. We were called, we have to at least see if she was okay, we explained.

"I'm fine," she said.  "I just want to go home."

"Why are you covered with leaves? I asked.

She wiped tears from her eyes.  "The kids robbed me and threw me in the bushes.  It happens all the time.  They like having their fun with me."

At least she seemed to have managed to buy and use some heroin before they accosted her. Her pupils were pinpoint and she had a weakness in her knees while standing. Perhaps the kids had been warned by the block enforcer not to rob her until she had contributed her few crumpled dollars to the day’s take.

"You don't hurt anywhere?"

"No, I just want to go home."

She was under the influence, but she was breathing fine and knew where she was when prodded. She let my partner do a head to toe survey on her and he found nothing significant. 

We couldn’t talk her into going to the hospital, but we did walk her the two blocks home to her apartment building where a neighbor who saw her walking with us agreed to look after her.  She told us she had narcan in her apartment.

After that day, whenever I saw Veronica on the street, I would have my partner pull the ambulance to the curb and I’d call out, “Hey, Veronica, how are you?”

She’d come to the ambulance window and we’d chat. I learned some things about her.  She was thirty-eight.  When she was little she wanted to be a dancer, but her bones were too brittle to stand up to the stress. She had once gone to New York to see Swan Lake on Broadway and she had ice skated at Rockefeller Center.  She turned to pain pills and then heroin for her bone pain and for other health reasons, which she did not elaborate. She said she stayed away from white heroin because she was afraid of overdosing on fentanyl, which had already happened to her twice, waking up looking at the paramedics. She snorted and did not inject as she was afraid of needles despite the butterfly tattoo I could see on her neck.  She stayed away from Chief, KD and the Fastrack brand. She made certain to keep narcan in her house and tried not to use alone, although she admitted she often did.

Last February we were at the substance abuse rehab hospital, waiting for a nurse to let us into the locked unit to take out a patient with a low 02 sat, when I saw Veronica come out of the entrance elevator and walk up to the admission desk. She was very pale and moved like every bone and muscle in her body was aching.

“Veronica,” I called over to her. “How are you doing?”

She looked about the room trying to locate the familiar voice. She likely wasn’t expecting to be recognized there.  When she saw me she forced a smile and nodded.

“Glad to see you,” I said. “This is your time. You can do it.”

She looked down at her feet, her face flushing. I wasn't certain if she was pleased I'd said hi or if  I had embarrassed her.

That was the last I saw of her for many months.  And then, just before Christmas, I spotted her walking alone on Park Street early in the morning. We pulled over and I called out her name. She came over, her head barely up to the window. When I asked her where she had been, she told me she had been staying with her sister in Woodbury, but then she had slipped up. Now she was back in Hartford. I told her I was proud of her for the months she’d been clean, and that she shouldn’t be discouraged. Relapse is a part of recovery for many. She did it once, she could do it again. The next time would be the charm.

"Thank you," she said.

I reached in my pocket and took out a Dunkin Doughnuts gift card. I always keep a few on me to give to homeless people. “Merry Christmas,” I said, than added, “It’s only for $5.”

Her face softened and she gave me a huge smile. She took it with one hand and with other, she reached for my hand, and gave it a squeeze. “Merry Christmas,” she said.

I watched her hobble down the street and wondered what her Christmas would be like, if she would be spending it with family and friends or if she would celebrate it by snorting a bag of heroin alone in her apartment.  I wished I had given her a few bucks to go with the card or maybe the orange I had with me.

I try to follow the users I encounter and see how they are progressing with their lives. Some I see regularly on Park Street; others disappear. I don’t know if they die or if they recover and are living productive lives or if they are just using on the streets of another city.

I can’t see the future, but every day people are still alive should be counted as a small victory for them, even if they fail in the end.

I still see Veronica around the neighborhood, and sometimes we talk.   I saw her this week on Park Street. It was a bitterly cold morning.  She was with three guys wearing hoodies, who I always see in front of the same shuttered store. She was doing a wobbly dance for them, prancing around, turning circles and waving a scarf in the air. She laughed and the dealers laughed too. They seemed to think her dancing was really funny like she was their court jester. They motioned for her to dance more, and she responded, flapping her arms like a butterfly.  I had a brief vision of her then just flying away, rising above Park Street, and migrating on to a better place.  The vision faded and all I saw was the men laughing as she stumbled.

My partner asked if I wanted him to stop so I could say hi to her, but I said keep driving.

Muscle Rigidity in Opioid Overdose

 

I wrote a number of months ago about fentanyl induced chest wall rigidity in opioid overdoses.

Chest Wall Rigidity

Fentanyl induced chest wall rigidity is rare in the hospital setting, but it should not be surprising to find it is a factor in overdose outside the hospital given that the amounts of fentanyl being injected are exponentially larger than in the hospital.

A typical $4 bag of properly mixed fentanyl sold on the streets of Hartford can be the equivalent of 1000 mcgs of fentanyl or 10 100 mcg fentanyl vials.  A bag with a hotspot of fentanyl would obviously have considerably more.

Since I wrote that post I had no further instances of possible fentanyl induced rigidity despite doing many ods.  That is until several weeks ago.

The call came in as a seizure in a restaurant that was closely associated with narcotic activity. We found the patient sitting awkwardly at a table at a table, looking almost like he was having a dystonic reaction. He was very stiff. His head was turned slightly to the left. One of the fire department responders said, “He’s on something.” The patient's pupils were pinpoint. He could react to stimulation and even say a few words, but he was too out of it to communicate with. We were able to stand him up, but we couldn’t get him to lay on the stretcher. When we finally picked him up, it was like picking up a cardboard cut-out of a man.  His legs were completely stiff and did not fall down with gravity. Out in the ambulance he was breathing at rate of six a minute and his ETCO2 was 99. His SAT was in the 80s. I got an ambu-bag out and started assisting his respirations. I did not meet much resistance, but I had difficulty getting significant chest rise, even after repositioning him a few times, and finally laying him flat. I palpated his chest, but it felt like a normal chest. My partner had given him 0.5 Naloxone IN, followed by a 2nd dose four minutes later. Only after she got an IV and gave him an additional 0.2 mg Naloxone IV did I begin to see chest rise and the ETCO2 began to drop. A few minutes later he woke up, and after initially denying he used any drugs, admitted that he had sniffed a bag that he told us must have had fentanyl in it. His respiratory rate was now 18 and his ETCO2 had dropped into the 30’s and his sat was 96%. We transported him, he had no further complications and was released from the hospital after a couple hours observation.

This week I read a new article, Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada, published in the Harm Reduction Journal. During the seven month study period Staff at Insite, Vancouver's supervised injection site, responded to 1581 overdoses, and documented 497 of these people having abnormal reactions, including 240 with muscle rigidity. The authors' write:

“Muscle rigidity ranged from jaw clenching to decorticate posturing with arms bent in towards the body, legs held out straight, clenched fists, and overall stiffness.”

In the article, they correlate the rise in abnormal reactions with the rise of fentanyl in the local drug supply.

Their conclusion:

"As the drug supply is increasingly contaminated with fentanyl and other synthetic opioids, overdoses may present with atypical features with or without other typical opioid overdose characteristics. It is important to recognize that muscle rigidity, dyskinesia, slow or irregular heart rates, confusion, and anisocoria may be observed as part of overdose presentations and should still be treated with naloxone and oxygen."

You can read the entire article here:

Harm Reduction Journal: Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada

Bottom Line:  If you encounter a seizing patient, a patient with muscle rigidity or a patient who may just seem hard to bag, and if you suspect that patient may have just used opioids, treat with naloxone.

***

Another fascinating tidbit from the article. Only 15% of these overdoses were transported to the hospital. In Hartford, almost 90% of our opioid overdoses are taken to the hospital with most being released from the ED either AMA or discharged after a couple hours monitoring. At the Vancouver safe injection site, after giving naloxone, the staff observes the patient right there in the facility. There were no deaths at the facility during the study period.