Balance

 I slept an extra half hour this morning. I was tired from my 12 hours in the city, and trying to get closer to the recommended eight hours of sleep, instead of the five or six I normally operate on. I joked with my wife that most of the signs and symptoms of COVID--headache, malaise, sore joints, body aches, shortness of breath -- are the same as symptoms of being a 61 year old.

At work at the hospital, I reviewed the previous evening’s admissions and checked for the corona lab results for patients who’d come in by EMS, and then I made the notifications to the EMS services. Some cases were obvious coronas and the crews documented full body precautions, but there have been others when the call came in not at all like a corona call -- a fall from a wheelchair or a psychiatric patient refusing to eat in a nursing home. I imagine an EMS worker getting a call from their supervisor. What's this about? Am I in trouble? The conversation starts with “Remember that call you did a few days ago...Well, the patient is positive for COVID. You may have been exposed.“ They may remember and think “Oh shit! I reached under the man’s arms, his back against my chest as I lifted him up.” Or the woman coughed on me and said she was a smoker and I didn’t think anything of it.

In the early days of this, they told us to mask up if the patient has a fever AND was short of breath AND had visited a foreign country where COVID was known to be in the community. That keeps changing.

Now I think we should be wearing a mask for every patient as well as putting one on every patient.

Provided we have enough surgical masks to go around. That is the hard balance.

On one side is our safety, on the other is the supply of EMS available to respond and the supply of PPE.

You have to protect us, but we can’t be protected to the extent that we run out of responders or PPE.  

The hard truth is that's what's happening.

***

At noon, I went home --I live just a couple miles from the hospital -- to fix my daughters lunch. They are both doing on-line school work. They convinced me to take them over to the schoolyard across the way and for an hour we hit softballs, playing home run derby. I felt like a young man again when I crushed three of my daughter’s soft lobs in a row over the little league fence. And I was even more proud when my daughters launched their blasts high and far into the early afternoon.  We could have played all day, but I had to get back to work. For all the bad that has come with this pandemic, getting to spend time with my daughters (20 and 12) and them getting to spend time with each other is treasured.

***

When I got back to the hospital, they were intubating a man not much older than me in the decon room right next to my broom closet sized office. He’d come in hypoxic, febrile and hypotensive. He’s up in the ICU in isolation while they await the COVID test. I added his name to the watch list.

***

Cases in Connecticut rose by 578 yesterday, but there were only two more deaths.

 

Beginning

 My wife met me at the door when I came home from working in the city last night. She made me strip in the foyer, dropping all my clothes – my jacket, my work shirt, my work pants, my tee-shirt, my socks—in the laundry basket she placed next to me. Then I was marched, clad only in my briefs, into the bathroom to shower. If it had been summer, I expect this all may have taken place in the backyard where she would have decontaminated me with the garden hose.

I did four possible COVID calls, gowning up in surgical mask, googles and large yellow paper napkin gown, and gloves. Two of the patients were hypoxic, one was burning up and had rigors that seemed to almost shake the back of the ambulance, and made it impossible to get an ECG tracing. The other two looked fine, but they had verbal complaints of fever, cough, body aches and malaise. At one of the hospitals I went to, they had us go into a decontamination room where we transferred the patient onto a hospital stretcher, and then a nurse came and wheeled that stretcher away while we took off our contaminated gowns. At the other, we waited in the triage line, which admittedly was pretty short as the only people going to the hospital today seem to be COVID patients, patients who think they had COVID or patients with psychiatric complaints.

When I was finally clothed in sweats and comfortable socks, I went downstairs to my computer and checked in on the hospital cases. The numbers are rising, and I had to make several notifications to EMS services of contacts with patients who tested positive for COVID-19. The governor on TV said the surge is beginning. He might be right.

Erie

 It is just eerie. I hear about what went on in China, what’s going on in Italy, what’s happening in New York. Covid is up here too, no doubt. But it is just his advance spies. The battalions haven’t reached us yet. At the hospital my office is on the left as you come in through the ambulance doors, just past it on the right is the resuscitation room. I watched EMS wheel in a not old patient with no medical history other than contact at a large gathering with people who tested positive for COVId. From my desk, I could hear the ED doctor call for the intubation tray. I watched them ready to take the patient up to the ICU. More and more of the stretchers that go by my door have a masked patient and gowned EMS crews. But the thing of it is, there aren’t many stretchers going by my door. Call volume is low. No one is coming to the hospitals unless they have to.

I walk out through the ambulance doors There are only empty parking spaces. We have a huge tent erected in the lot. It is to be used when we are past capacity. It hasn’t seen a patient yet.

Our hospital is on top of a hill. I walk out to the edge of the lot and I look out over the valley and other Connecticut hills. They are peaceful. No sirens in the distance.

I think of the patient in the ICU and the few others up there with him. There are still many empty beds. Ventilators sitting idly, but ready to be put in service.

I drive home, the only car on the road. Two cars are parked in most driveways. Older couples are out walking two by two. I wonder if next week, I will be responding to this neighborhood, to any of these houses. If their residents will be febrile and struggling to breathe, too weak to make it to their cars, too sick to last much longer at home.

Maybe tomorrow COVID will appear on the top of the hills ready to descend down and join its advance spies seeded among our community.

I have my freshly washed uniform laid out for me when I rise in the dark of tomorrow’s morning. My boots are by the door. Ready for battle.

***

Of the 1291 cases confirmed in Connecticut by Friday night, only 189 of them were in Hartford County with only 2 of the 27 deaths.  Only 173 hospitalized in the state with only 36 hospitalized in Hartford county.  I may start tracking the dead and hospitalized number as they may be a better tracking of the epidemic due to limited testing availability.  Roughly 15% of the confirmed cases were hospitalized (counts the dead) so far.

Source: Connecticut DPH.

***

Latest figures released Saturday evening.  1524 cases with 33 dead.

Closed Down

 A couple weeks ago, they cancelled my daughter's basketball championships.  Her team was in the state semi-finals and had a good shot at winning it all.  The championships were going to be in a high school gym where maybe fifty people would come to watch her sixth grade Catholic league  team play.  The NBA was still playing then before packed crowds.

I was supposed to speak at a conference in Washington D.C.  about Connecticut's opioid overdose surveillance system, which I helped set up.  The federal government was going to pay for my trip.  I just had to submit the receipts.  I was a bit worried about the COVID things so I bought insurance on my air flight.  Good thing.  Because the head of UCONN banned university employees from going on out-of state trips.  I had 72 hours to cancel my hotel reservation, but unfortunately, I was between 72 and 48  hours and since I had to reserve the room with my credit card, I got stuck with a night's fare.  I was a little annoyed because at the time, the UCONN basketball team was still traveling and playing in front of crowds.  

One of my biggest joys is swimming.  I get off work and I go to the pool, and I swim.  Its feels great.  It washes the city's grime off me and when I get home, I am decompressed, calm, relaxed, not tense and agitated.  Plus, swimming is great for my back.  I have two bulging discs and sometimes have trouble feeling the backs of my legs.  The swimming makes it better.  Lately, the pool had been pretty empty.  Sometimes just me in the eleven lane pool by myself or one or two other people, particularly when I got off work late.  They closed the pool.

They cancelled my daughter's spring softball season.  Her AAU basketball season is on hold.  What joy I get out of watching her play.

They have a little gym at my hospital.  It's a five minute walk from my desk.  I go there and I am often the only one.  I ride the bike, I hit the weight machines, even the free weights. Do some stretching on a yoga mat.  Again, great for the back.   I take a quick shower and I'm back at my desk, refreshed and fit.  They closed the gym.

I just went part time on the ambulance after 25 years full time.  I thought I'll still be able to pick up two, three shifts a week.  Then people stopped going to the hospital.  They're scared.  With the volume down, they are cutting cars.  No more open shifts.  No more calling in and saying, "Hey you need me?" and hearing, "How fast can you get down here?"  I'm getting maybe one shift a week now and I have to sign up well in advance.

My daughter and I went to a nearby playground yesterday.  The place was deserted.  We were going to shoot some hoop.  Here's what we found.  They had a wood board over all the hoops.  The park across town where we sometimes shoot just by ourselves, they took the rims off.

Whine.  Whine. Whine.

It's a new world.  At the hospital, I have to have my temperature taken every morning just to get in the building. They only allow three in the elevator at a time.  I have to wear a mask all day.

But, you know I have to hand to the people making the decisions.  They are doing their best to keep this thing under control.  Doing their best to flatten the curve.  They'll be days ahead to swim, and play basketball and work out, and watch my daughter play sports.  And I'm sure they'll be plenty of shifts ahead when the storm hits.

Right now its about saving lives.  Slowing the spread.  Social distancing.  Keeping people safe.

You can't be against that.

1291 cases in Connecticut, and this is with limited testing.  Hear the drumming.  27 dead.  More to come.

We're all in this together.

A Bandana and a Serape

 When I started in EMS in Massachusetts in 1989, in only one of the three towns I responded in were their first responders and in that town, the fire department first responder was a single fireman in a bronco, not an engine with a four or five man crew. (For those not in EMS, a first responder is a service that responds to the scene in addition to the ambulance. In our state, first responders are typically police and fire). In Connecticut every town has a unique EMS system with a unique array or responders. In one town you will get us in the ambulance along with a police officer; in another you will get a police officer and sometimes two fire engines, the second comes if the first one doesn’t have its own paramedic.

I just went on a call in another town where I arrived at the same time as the fire engine. Four people jumped out all already wearing their N95 masks. They raced in ahead of me, and two stood around the patient when I finally made it up the two flights of stairs to the patient’s room. I did my questioning from six feet away and determined neither the patient nor I (nor the first responders) needed a mask. The caller had no fever, no dyspnea, no cough. The FD used 4 masks that we are only supposed to use then performing aerosolizing procedures on high-risk patients.   Plus for the FD to enter the house and expose themselves when the patient was able to walk out on his own power is an added danger that accumulates with entry into each home or 911 scene.

When you see a fire chief on TV begging for more N95 masks, you might want to ask him how many responders he is sending in to each call and whether or not an ambulance is also there. In the end, only the ambulance is truly essential. Someone has to take the person to the hospital. Let’s save our first responders from unnecessary exposure and save our supply of PPD so when medics have to perform procedures like intubation or giving a nebulizer, they have a better mask than a surgical mask available.

***
Some say this is the PPE of the not too distant future after we have run out of masks and gowns.

 

 

 

 

 

 

 

 

A bandanna, a serape, and a gun.

***

I was a bit of a first responder myself last week, working in the city fly car, which I do periodically. I responded to the fire dispatch which is usually always a minute or two before the ambulance dispatch. I cut our response times considerably, but often I just turn the call over to another medic after only being with the patient for a minute or two. If the responding ambulance is BLS, then I ride it in if it is an ALS type call. One call was for a patient with fever and respiratory distress. A supervisor told me not to respond. The response delay was only a minute  and what was the sense of getting another person exposed to a potential PPE patient, as well as having to use another body isolation kit, which we are supposed to don for clearly identified high risk patients.  And like most respiratory distress calls we are dispatched to, the person's problem was more chronic than acute.  They transported to the hospital without lights and sirens.

***

At our hospital, we sent the following advisory out:

Dispatch Modification Recommendations to Municipalities for First Responders

In an effort to reduce the exposure of emergency medical first responders, many of whom are relied upon for providing critical law enforcement and fire protection to the community, municipalities should consider the following:

Only dispatch first responders to patients when one of the following critical findings is identified:

Case Entry Questions:

Is s/he conscious? - caller answers “no”
and/or
Is s/he breathing? - caller answers “no” or indicates ineffective breathing

Key Questions:

If the patient is reported to be conscious and breathing during case entry, first responders should only be assigned
under the following circumstances:

Chest pain in anyone over 35 years of age

Difficulty breathing as a chief complaint or component of another medical or traumatic complaint

Altered level of consciousness is the chief complaint (excludes not responding appropriately when identified during key questioning; excludes “altered mental status”)

Severe hemorrhage is reported at any time

Imminent childbirth

First Responder Patient Assessment:

Limit the initial number of personnel entering the scene (area of patient contact) to one unless the situation dictates more enter the scene (e.g. cardiac arrest).

The remaining crew should stage outside the immediate scene and be ready to assist the crew member inside if requested.

Screen all patients for COVID-19 (observing 6 feet separation during initial phase), use appropriate PPE, and place a surgical mask on any patient who screens positive for COVID-19 symptoms.

Additional personnel should only enter when needed for care or extrication as requested by the primary responder.

If determined that the patient is not at imminent risk and would not benefit from care by the first responding unit, delaying patient contact may be considered when the second unit is either an ambulance or a responder of higher certification.

Patient care should never be delayed if imminent risk cannot be ruled out and/or life-saving care is needed that can be provided by the first responder (CPR, hemorrhage control, etc.).

Properly doff PPE, clean and disinfect equipment and dispose of material according to agency protocol/policy.

***

Be safe everyone.

Released Prisoners, COVID, and Substance Use

 

Many prison systems in the United States are admirably releasing low risk prisoners to try to prevent an epidemic of COVID-19 from ravaging the inmate populations, particularly in crowded prisons.

Neglect of Prisoners During Coronavirus Pandemic Threatens to Further Escalate the Current Crisis

US jails begin releasing prisoners to stem Covid-19 infections

While a great, humane and life-saving idea, it does create an ancillary problem of many drug-users being released to the streets with lower or no tolerance. With social distancing and self-isolation, many of these users may find themselves using alone.  The overdose death toll is likely to rise.

Prison release officials, harm reduction workers, including us in EMS, should help spread this message from the Yale Program in Addiction Medicine:

AVOID INJECTING ALONE: The illicit drug supply continues to be toxic. Be careful about risk of overdose. Try not to use alone, especially if you inject drugs like heroin, fentanyl, or drugs that might have come into contact with them. There are a couple of things you can do to try to stay safe: (1) You can reduce your risk of COVID-19 infection by staying at least six feet away from other people, coughing or sneezing into your arm, avoiding touching your face, and washing your hands for at least 20 seconds with soap and water. (2) If you have a phone, call someone, preferably nearby, and ask them to stay on the line while you are injecting so they can act or call 9-11 if you become unresponsive.

Guidance for People Who Use Substances on COVID-19 (Novel Coronavirus)

We are all in this together.

 

Closed Down

A couple weeks ago, they cancelled my daughter's basketball championships.  Her team was in the state semi-finals and had a good shot at winning it all.  The championships were going to be in a high school gym where maybe fifty people would come to watch her sixth grade Catholic league  team play.  The NBA was still playing then before packed crowds.

I was supposed to speak at a conference in Washington D.C.  about Connecticut's opioid overdose surveillance system, which I helped set up.  The federal government was going to pay for my trip.  I just had to submit the receipts.  I was a bit worried about the COVID things so I bought insurance on my air flight.  Good thing.  Because the head of UCONN banned university employees from going on out-of state trips.  I had 72 hours to cancel my hotel reservation, but unfortunately, I was between 72 and 48  hours and since I had to reserve the room with my credit card, I got stuck with a night's fare.  I was a little annoyed because at the time, the UCONN basketball team was still traveling and playing in front of crowds.  

One of my biggest joys is swimming.  I get off work and I go to the pool, and I swim.  Its feels great.  It washes the city's grime off me and when I get home, I am decompressed, calm, relaxed, not tense and agitated.  Plus, swimming is great for my back.  I have two bulging discs and sometimes have trouble feeling the backs of my legs.  The swimming makes it better.  Lately, the pool had been pretty empty.  Sometimes just me in the eleven lane pool by myself or one or two other people, particularly when I got off work late.  They closed the pool.

They cancelled my daughter's spring softball season.  Her AAU basketball season is on hold.  What joy I get out of watching her play.

They have a little gym at my hospital.  It's a five minute walk from my desk.  I go there and I am often the only one.  I ride the bike, I hit the weight machines, even the free weights. Do some stretching on a yoga mat.  Again, great for the back.   I take a quick shower and I'm back at my desk, refreshed and fit.  They closed the gym.

I just went part time on the ambulance after 25 years full time.  I thought I'll still be able to pick up two, three shifts a week.  Then people stopped going to the hospital.  They're scared.  With the volume down, they are cutting cars.  No more open shifts.  No more calling in and saying, "Hey you need me?" and hearing, "How fast can you get down here?"  I'm getting maybe one shift a week now and I have to sign up well in advance.

My daughter and I went to a nearby playground yesterday.  The place was deserted.  We were going to shoot some hoop.  Here's what we found.  They had a wood board over all the hoops.  The park across town where we sometimes shoot just by ourselves, they took the rims off.

Whine.  Whine. Whine.

It's a new world.  At the hospital, I have to have my temperature taken every morning just to get in the building. They only allow three in the elevator at a time.  I have to wear a mask all day.

But, you know I have to hand to the people making the decisions.  They are doing their best to keep this thing under control.  Doing their best to flatten the curve.  They'll be days ahead to swim, and play basketball and work out, and watch my daughter play sports.  And I'm sure they'll be plenty of shifts ahead when the storm hits.

Right now its about saving lives.  Slowing the spread.  Social distancing.  Keeping people safe.

You can't be against that.

1291 cases in Connecticut, and this is with limited testing.  Hear the drumming.  27 dead.  More to come.

We're all in this together. 

875

 It was slow at the hospital, only three patients in the ED when I got to work. A doctor said to me, these past two weeks have been like low tide, when the water recedes way farther out than normal, so far out that all you can see are rocks. But you know that when the tide comes back in, it’s going to be a raging tsunami.

People who can avoid coming to the ER are avoiding it. Some of the people who come in during the course of the day have weakness, body aches, fevers and cough. They don’t all have COVID, but they could, so they treated as if they do. They need to be isolated, and the staff needs protective gear to treat them.  Tests go out. Some come back a day or two later ruled out, others rule in.

Many who have COVID don’t need to go to the hospital. Some will be sick enough that they finally do.  Some will need ICU care. A few of these will need ventilators.  Some may die.

At some point the cases may exceed capacity. That’s the fear. That’s the reason for the social distancing. Flatten the curve.

At some point in April or May or June, we may be swept up in that tsunami.  For right now, we wait.

Connecticut cases are up to 875 and 19 deaths.

 

 

Covid Test?

 I was dispatched to intercept with a BLS unit for chest pain. I met them on the side of the road where the EMT told me the patient had a severe chest pain that's worse when she coughed. She said the woman had a COVID test the day before and it was negative.

I nodded and got in the back where the woman on the stretcher was moaning as she coughed.

“So you had a COVID test yesterday?” I asked.

"Yes, I already told them that," she said, clearly annoyed.

“And it was negative.”

“Yes.”

"Where did you have it?”

“At the community health center.”

That made me pause a moment. I didn’t think they were testing, but what do I know?

“And what did the test consist of?” I asked.

"They stuck a thing in my ear and looked at it and said I was okay.”

“Put this one,” I said, handing her a surgical mask.

I put mine on next.

***

I did a call for an unresponsive in the bushes. The man was drunk, but responded to stimulation. When the police officer patted him down, he found a small hand held vial of Purell. Boy did that change how he was treated. “You’re a rich man, governor.” “Make certain they put in that in the safe when you get to the ED.” “That’ll buy you a week’s accommodations with an open bar at the Holiday Inn.” “You’ll need a butler, I could use some extra income.”

Good to see people still laughing.

***

I’m in the fly car again today, and I have in the back seat a box with extra protective gear. Each ambulance is only issued two sets (one for each crew member) of protective gear, which includes a gown, protective glasses. They are issued 4 N95s for the truck and 4 surgical face masks. If a crew uses them now, instead of having to go off the road and return to the base for supplies, I can just swing over to the hospital and give them a fresh set. I am daydreaming away skipping town with them. But where would I go? In the movies, the bank robbers always dream of a little fishing village in Mexico, but I’ve heard COVID cartel has already staked claim to those parts. Nowhere is safe.

***

At the base this morning, many of my coworkers were talking about how the gun stores have been jammed lately. Another medic said he wasn’t buying any new guns because, he said, once the shooting starts, there will be plenty of guns laying on the ground for the picking.

Someone sent me a video of a what seemed like a mile-long train carrying armored vehicles and tanks headed who knows where. Hopefully, not to our city. 

I tried to google the video for more info and all I could find was old clips so I have no verification this is actually happening today.

***
They advise you not to read the news to relieve stress. I am torn. I want to know everything there is to know about what’s going on, but it stresses me deeply. I don’t sleep well at night, having wild dreams about corona who looks just like Sponge Bob with wild wavy arms chasing after me.

I was surfing the net the other day when I came across some memes that made me laugh.

An XXL Serving of Corona-Virus Memes to Enjoy During Quarantine

This was my favorite:

***

If you haven’t seen it this is a great explanation of social distancing.

 

https://www.instagram.com/p/B-CcmHGn4EW/?igshid=1wqtri5de5dp5

***

Three best new stories of the day:

Why this Nobel laureate predicts a quicker coronavirus recovery: 'We're going to be fine'

The doctor who helped defeat smallpox explains what’s coming

Restaurants donate armloads of food to area hospitals to support health care workers amid coronavirus crisis

***

COVID 19 and Substance Users

 My friend Rosie is hanging out in front of El Mercado, surveying the street. She smiles and hurries over when she sees our ambulance pull to the curb. I give her an apple, which she starts eating like it is all she has had to eat today, which it likely is. I also give her $5 bucks. I’ve been worried about how she has been coping the last week with the COVID news and the business closings and the stay at home messaging, wondering where she will get up the money to get her bag of fentanyl every four hours, much less get some food in her system. She shrugs when I ask. “Nothing’s changed, “she says. The market’s still open, the dealers are still open for business. The street is still plenty of traffic.  She is fifty years old, and not in the best health. Yes, she is worried about getting the bug, but it is not as high on her list as getting her next bag of heroin.

She’s right about not much changing yet.  Today, the dudes on the corners and the ones in the tinted windows in the cars parked just off the main way are still at it. I can still see the surreptitious handshakes, passing money for bags of dope, and the big chest bumps. The only social distancing is the usual, you stay in your territory, I’ll stay in mind. And if you are in your own territory, why not all stand together.

Overdoses, while not at their summer highs are holding constant.

I listened to a conference call the other day about how the COVID epidemic might affect those with substance use issues, and it was pretty scary.

Here are some of the main points.

1. Expect drug supplies to be disrupted, causing some users to suffer withdrawal, and other users to buy from unfamiliar dealers, exposing themselves to the danger than unfamiliar mixtures can entail.

2. Most in person recovery meetings have been cancelled and replaced by on-line virtual meetings. That’s okay for those with computers, but no so good for the have-nots.

3. The closing of outpatient mental health and substance use centers, gyms and other outlets some people rely on to help them keep from using may lead to relapses.

4. Imposed isolation on people with mental health disorders is a recipe for disaster.

5. COVID may spread wildly among homeless users.

6. Even those with mild COVID respiratory issues will be at higher risk of overdose as most drugs affect respiratory functions.

7. restricted access to syringe service programs will lead to higher rates of HIV and Hepatitis C.

8. When the corona patient overload hits the EDs, there will be less space and time for overdose patients or those seeking recovery, leading to quicker discharges and less in hospital services.

The Greater Hartford Harm Reduction Coalition has been spreading information to their clients, warning of the dangers of COVID-19.

Guidance for People who Use Substances on COVID-19

We are all in this together.

The Five Second Rule

 

You know the five second rule. You drop food on the floor and as long as you pick it up before five seconds have passed, you can still eat it without worry of getting sick from the bacteria that was on the floor. That is because the bacteria as a fellow living species gives us those five seconds. Now whether they do it as a courtesy or whether it just takes them 5 seconds to recover from the asteroid falling out of the sky and killing their neighborhood, before they can get their act together and shout, “Let’s get em!” I don’t know. I just know you have five seconds.

The CDC’s “prolonged contact” rule” which has been interpreted as 15 minutes by a local hospital, is of the same scientific school of thought as the five second rule. It seems they have inside information that COVID, which has been terrorizing the planet, is willing to wait until 14:59 plus one second before it latches on to anyone. Maybe killing has come so easy to it, it has decided to take a breather and give us that 15 minute safe zone. When I see, nurses gowned up in space suits to test a drive-up patient, I want to say them, “You don’t need all that as long as you plan to keep your patient encounter under 15 minutes.”

The CDC must know this too, or maybe they know the rule only applies to EMS workers. Maybe they held a secret negotiating sessions with Covid, and Covid seeing what easy prey we were agreed to cut us some courtesy time because it knows it's going to get us in the end anyway.

***

Below is the CDC recommendation, and I see they only say a few minutes is reasonable to be considered prolonged.  I am trying to find out why some local hospitals have extended that to 15 minutes.

Close contact for healthcare exposures is defined as follows: a) being within approximately 6 feet (2 meters), of a person with COVID-19 for a prolonged period of time (such as caring for or visiting the patient; or sitting within 6 feet of the patient in a healthcare waiting area or room); or b) having unprotected direct contact with infectious secretions or excretions of the patient (e.g., being coughed on, touching used tissues with a bare hand).

Data are limited for definitions of close contact. Factors for consideration include the duration of exposure (e.g., longer exposure time likely increases exposure risk), clinical symptoms of the patient (e.g., coughing likely increases exposure risk) and whether the patient was wearing a facemask (which can efficiently block respiratory secretions from contaminating others and the environment), PPE used by personnel, and whether aerosol-generating procedures were performed.

Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure. However, until more is known about transmission risks, it is reasonable to consider an exposure greater than a few minutes as a prolonged exposure. Brief interactions are less likely to result in transmission; however, clinical symptoms of the patient and type of interaction (e.g., did the patient cough directly into the face of the HCP) remain important. Recommendations will be updated as more information becomes available.

Risk stratification can be made in consultation with public health authorities. Examples of brief interactions include: briefly entering the patient room without having direct contact with the patient or their secretions/excretions, brief conversation at a triage desk with a patient who was not wearing a facemask. See Table 1 for more detailed information.

Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

15 Minutes

 Confusion and Unease. That’s what I would say is going on now out here in EMS land.

Listen up:

First the government told us we had to wear N95 masks when faced with a potential COVID patient. Then we were told a simple face mask was fine. The CDC then issued more revised guidelines that defined risk, saying as long as you did not have "prolonged contact" with a patient without wearing a mask, you were okay. 

Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

Now a hospital in our area has defined prolonged contact as 15 minutes. They are saying, if you are without a mask for the first fifteen minutes, it doesn’t count as an exposure.

Read this for yourself:

Once on the scene, and as soon as possible, a patient with suspected infection as per the most current CDC recommendations and guidelines should be provided with an isolation (surgical) type mask to wear. Responders should likewise don an isolation mask. If an isolation mask is worn by EMS providers within 15 minutes of initial contact, they will not be considered as having been exposed even with contact to a patient who has tested positive.

Where does that 15 minutes come from? What science is that based on? Are they saying it takes 15 minutes of exposure for someone to get COVID? We can get coughed on and respiratory dropletted upon for up to 15 minutes and we will be okay?  Come on.

We have also heard that at several services, even if you are exposed, you should keep working until you are symptomatic, even though it is known you can spread the disease on to others before you yourself show symptoms.

Many people are angry about this relaxing of restrictions because the relaxing seems more linked to the supplies and the need to keep a sufficient health force working than true safety.

Add that to our understandable paranoid belief that EMS worker safety might not be the top concern with higher ups and throw that against the onslaught of news describing the terrors of COVID, “the perfect killing machine,” and people are rattled.

Here is what I believe:

Most Americans (70-80%) are going to get COVID eventually. (This includes many who have or have had it or will get it and not know.)

The effort at social distancing and closings are geared to flatten the curve (spread the sickness out over time) and keep the health care system from being overwhelmed, enabling it to save more COVID patients as well as other sick patients who will need ICU level care.

These efforts will fall short, but will be better than no effort at all.

We will have a true period where the shit hits the fan. Likely beginning in May.

The ever changing guidance to EMS reflects the need to find a balance between safety and not exhausting the supply of PPE and the supply or EMS responders. If you insist on the proper level of safety, too many of us will have to be self-isolated and there will not be enough PPE to make it through.

We are given a limited supply of PPE and told to only put it on when we encounter someone with a fever and symptoms of respiratory illness and possible contact with a positive patient. Yet we walk into a hospital and everyone is wearing masks, everyone except EMS. You see pictures in the paper of nurses gowned up in space suits to do COVID testing, wearing full body gear that looks nothing like the paper napkin gowns they give us for the most extreme cases, a gown that in my case doesn’t even reach my knees. You can see why people feel uneasy.

Many like me are resigned to getting it. I hope that my 15 day January/February illness was COVID, but I fear waking up each morning with a raging fever. I’m 61 and am in good health for the most part. I have read enough to understand most of those dying are old and with comorbidities that I do not have.  I want to work.  I love being a paramedic, and have always been and am still willing to be on the front lines.  Like those I work with, I will take the risk.  Just be honest with us about them.

***

The governor has shut down much of the state, but working in the city today, it didn’t feel much different, people still gathered in the park in groups or on the corner and there were a lot of cars on the road, nothing like the scenes we have seen of cities on lock down.  Each day the restrictions grow severer.  Starting on Monday, all nonessential businesses will be closed.

The confirmed COVID case numbers in Connecticut shot up again today to 194 with 4 confirmed deaths now (all in their 80s and 90s).

These case numbers while rising are still way low because there has still been so little actual testing.

96

 Connecticut had its first confirmed COVID death today, an 88 year-old nursing home patient. The number of confirmed cases is up to 96.

Because of the COVID virus, we cancelled our monthly hospital sponsored in person EMS CME. Instead we held it on-line through an app called WEBex, which is available to our hospital. I was nervous about using the technology for the first time, but I thought it went very well aside from a few unmuting issues. People were able to view it from their homes or at their EMS stations. We had over 71 callers, with many of the callers hosting multiple viewers. Think of all the time and gas saved. Viewers were able to ask questions through the chat function. Afterwards, I emailed CME certificates to those who requested them. We are going to be holding our CME’s this way for the foreseeable future. I wouldn’t mind making them permanent. Holding them online seems much more efficient. More people can attend with less time involved.

Our featured speaker was our infectious disease expert, who had reliable, up-to-date information for us about the epidemic.  You can watch the recording here:

UCONN EMS CME-COVID 19

Traffic into the hospital was slow today. We had a number of suspected COVID patients, who were all placed into isolation rooms. Those sick enough to be admitted received tests that were sent off to the state. Those not, were sent home to self-isolation. Connecticut still has a severe shortage of tests, which restricts those who we are allowed to test.

For EMS, be careful. Every patient is a potential COVID patient. Accidental exposures may occur. The CDC has updated guidance on exposure and risk assessment.

Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)

The worldwide corona news continued to be back and forth. One article made me feel better that in Italy 99% of the patients who died had comorbidities, while another article warned this epidemic in the United States will last another 18 months with massive economic consequences and shortages. Oh, boy

The stock market tanked again.A few days ago, I looked at my 401K for the first time and was actually surprised my losses weren’t greater. Instead of being 100% invested in stocks, I am 50%, The rest is in cash or bonds. My father taught me that when it came to stocks, you could be aggressive or conservative, but you should settle on a mix that lets you sleep at night. I debated briefly selling everything believing there is bad news to come, and then I debated buying more believing that the best time to buy is when everyone is fearful. In the end, I decided to just leave it alone. One less thing to worry about if I bet wrong.

The governor took more action today, closing amusement parks, bowling alleys, and indoor shopping malls.

I have been taking my daughter to the park to hit softballs and then shoot baskets in the evenings. I was distressed to both see a picture of locked up basketball courts in the paper and to hear Steven A Smith on ESPN sports radio blasting people for playing hoops in the park and violating the spirit of social distancing. We are not playing five on five shirts and skins full court, we’re just shooting baskets, the two of us, trying to get some fresh air and normalcy.

I guess CNN played some video of people in San Francisco jogging along the street. There were a lot of runners. San Francisco, unlike Connecticut, is under lockdown where people are only supposed to go outside for essential business, which includes exercise as long as distance is met. The announcers were outraged, but I wonder if maybe the cameras were just panned on a highly traveled intersection, while the rest of the streets were empty. This is like when the TV during storms shows cars underwater on the only street in town that is actually flooded. I don’t know.

I was going to take my daughter to the sporting goods store to see about buying a portable outdoor hoop for our small driveway, but my wife yelled at us and told us not to leave the yard and listen to the governor, and stay home. My wife is Jamaican and it is best to heed her when she gets heated. My daughter ended up crying in her room and I had to talk with her. While this COVID is stressful to us all, we need to watch our children and help them through it.

I don’t like where this is headed.

41 Cases

 The New York Times is reporting a new study out of London that predicts 2.3 million Americans will die without more action by the government with the bulk of the deaths coming in June.

White House Takes New Line After Dire Report on Death Toll

Connecticut is up to 41 confirmed cases.  No deaths yet that I am aware of.

My office is by the ED entrance. More patients are coming in with masks on and crews wearing N95s.

We had a positive COVID-19 case where EMS did everything perfectly, putting a mask on the patient, wearing N95s, calling in ahead to alert us of the possibility. Great job!

Two hundred Connecticut nurses at one hospital are in isolation due to exposure from a patient and they are unable to get tested.

200 Connecticut Nurses Exposed To Coronavirus Sidelined Due To Lack Of Testing

We are working on plans at our hospital for separate ED entrances and wings for those suspected of COVID and those not.

I talked to a doctor today who thinks COVID has been in our community for months, but not recognized due to unavailable testing. I sort of hope this is the case, as I was sick for about 15 days in January and had a couple days I could hardly move. I didn’t have a recorded fever, but I was taking Tylenol day and night.

Connecticut has closed all restaurants, bars, movie theaters and gyms in the state, and are limiting gatherings to 50 or less.

Stop and Shop, my local grocery store, sent me an email announcing that as someone over 60, I can enter the store at 6:30 in the morning, an hour before the general (raging horde) public to enable me more social distancing and spare me the rush against younger rougher shoppers. I went yesterday before this policy and a fellow older shopper tried to trip me while he lunged for the limited fresh blueberries. Maybe he thought I was going to get to the frozen pizzas before him.

Meanwhile, someone has been stealing canisters of Purell off the hospital walls.

Quiet

Our hospital had its first COVID-19 case, a 59-year old Hartford man who had already been released to self-isolation when his test came back positive. Hartford Hospital had its first a few days ago. They timed their press conference with the start of the 10:00 PM news. The patient is 88 and comes from a suburb just south of Hartford. No other details were reported.

A friend of mine, who hasn’t been feeling well, went to another local hospital where he got swabbed in his car, with the sample sent off to Washington state. He should hear results in a week. In the meantime he is staying home.

School was suspended for both my 12-year-old daughter and my college sophomore daughter, who is now home with us. I stopped by the supermarket to get some more groceries to feed the larger household and found many of the aisles bare. All fresh and frozen vegetables gone. Chicken and hamburger gone. Paper towels and toilet paper. Gone. Hand sanitizer and wipes, forget about them. It’s getting crazy. They even shut down the town pool where I swim every night. I swim to clean the city off me, to separate the outside world from my inner peace. Plus, the chlorine would be great for getting rid of any lingering corona and other germs so I can come home peaceful and pristine. They closed the pool.

I continue to read the news, which just increases my angst. One article reassures me that the virus is mild in most cases, the next describes Corona as “the perfect killing machine.” An article says China is getting back to normal, another one describes a near zombie apocalypse in Italy.

My wife just texted me about an interview with an Italian doctor that has her as upset as I have ever known her to be. She begs me to take precautions and be careful to protect my children and family while I am at work.

Here on the ambulance today there is a nice folder of handy reference information on the outbreak with everything about how to properly screen a patient for COVID-19 to how to clean the ambulance after each patient. The “foreign travel” screening question has been changed to “Have you traveled to a HOT area where there are known corona cases?” It mentions that our state is one of them.

It was slow today. I didn’t need to put on a face mask for any of my patients. Most, but not all the churches, were closed. The hospitals seemed close to empty. In the EMS rooms, the TV newscasters made more dire predictions about how long the epidemic was going to last. One health expert said the best thing would be for everyone to stay in their homes. I was the only one in the Jamaican restaurant I went to for breakfast. Next door was a market that was empty of people, but fully stocked. They had toilet paper and paper towels and all those things that had been ravaged from the suburban market. I guess in Hartford people don’t always have the spare money to stock up on supplies.

The paper said in a few days when the tests start coming back, we may have thousands of cases in the city. I can’t believe the quiet will last much longer.

It was a beautiful day today. In the afternoon, we got posted to the suburbs for an hour while their town ambulance was on a call. I brought my basketball and shot baskets for about twenty minutes in a park where nearby three dads were playing baseball with their young sons. When I get off it will still be light, and I am hoping to take my daughter to the park, too.

  

Waiting for Corona

 

Connecticut is up to 11 confirmed cases, but none in the Hartford area yet. This is a bit misleading as my understanding is very few people have been tested in our state (The Hartford Courant reports 136 have been tested) due a shortage of test kits and the start up time it takes new labs to set up.

I worked in the city today and it was quiet. The hospital waiting rooms were not crowded at all, which is unusual. I saw a Park Street bus go down the street with not a passenger on it, but the streets weren’t empty. The same people who always stand on the corners were at their posts. There was plenty cars driving about, a few with masked drivers.

Before we went on the road we had to checkoff our protective gear – two full isolation packages, four N95 masks, surgical masks, two eye protection glasses, decon wipes, and hand sanitizer.

I talked to two homeless heroin users today. One said she was very worried about the virus. She said she was trying to wash her hands whenever she could; the other just shrugged. Corona was the last of her concerns. She still needed a few dollars to buy her next bag of dope.

My last call of the day was for a woman with a sudden onset of body aches, chills, and nausea with dry heaves. Her skin was hot and her heart was banging away at 120. She had no foreign travel, and no one she knew was sick. I asked every question I could think of to elicit some information that might reveal that she met Corona criteria, but I struck out. I gave her some fluid and four mgs of Zofran. I suppose if she ends up having had COVID-19, someone will be letting me know.

The foreign travel question is going to have to change with all the reports of Americans getting Corona without any foreign contacts. Pretty soon, the question is going to be “Have you left your house at all in the last 14 days?”

At one of the hospitals this afternoon, the ED staff was screening two people in a car. The passengers each had mask ons, and the doctor was fully gowned up with a face shield, and the nurse had a N95 mask as well as full body protection. The doctor had a clipboard and the nurse had a portable BP machine out by the car.

When my shift was over, I stopped by the large Chinese supermarket by our office. The place was sparsely populated with a noticeable number of shoppers wearing masks. I bought some barbecue pork, green vegetables (snow peas and bok choy), dried noodles, and frozen dumplings. Yesterday I went to the local stop and shop and it was in full scale panic. The governor had outlawed any gathering of 250 or more people, but I tell you there were five or six hundred in that store. No chicken. No frozen vegetables. No toilet paper. I didn’t see a single mask.

I’ve been buying steady so we are in good supply at my house. Tonight we stay home and watch TV together.

It may only be a few days till Corona is in our town.

Protective Measures

 Our Corona response all comes down to this graph:

 

Source: New York Times

All the cancellations, social distancing, self-isolation, hand-washing is about slowing the inevitable spread of the disease so the health care system is not overwhelmed.  

Years ago I worked on a factory assembly line and the ideal was for the line to go a little bit faster than you were comfortable with so you could achieve maximum performance.  If the line went too fast, hit the breaking point, then everything fell apart.  The line spiraled out of control.  People just stopped and gave up as parts fell off the line and what product did get assembled  was done so badly, it had to be rejected.  We can't let that happen to our health care system.

Without protective measures, people will die who otherwise wouldn't have.

Breach

 

COVID-19 has breached our state borders. There are four confirmed cases in Connecticut.  I was supposed to fly to Washington today for a federal opioid conference, but the University of Connecticut president issued a decree cancelling all domestic travel for its faculty and staff. (1,2) The governor weighed in two days later and cancelled all domestic travel for state employees.

While I was looking forward to the conference, cancelling the trip at least spares me the horror of having a coughing fit on the plane and ending up being escorted off the plane by men in space suits and quarantined on some obscure naval research base.  

I worked the ambulance Monday.  Twice, I was screened on entering a building on a call.  One was at the VA, where three masked nurses asked me if I had any flu symptoms or had traveled out of the country.  I got the same questions at a nursing home, but they sort of let us through as they were soon overwhelmed by fire and police responders all racing past.  

My first patient had a fever, a cough, nausea, vomiting and diarrhea.  But she hadn’t been out of the country for sixteen years and probably hadn’t been out of her home hospital bed for at least that many months.  Another patient had a fever, but he had a septic hip, and also hadn’t been out of the country or had contact with anyone suspected of having COVID-19.

I washed my hands a ton of times.  I ponder. If a hospital has a five month supply of Purell, but because of Corona fears, people are using Purell five times as much during the day, doesn’t the hospital just have a one month supply?  I did run across a couple empty wall containers today that hopefully got refilled.

I didn’t work for a week so I was curious what the feel of the street was as far as corona.  Washing hands. Yes. Wiping down the stretcher. Not so much. I tried to make certain to strip the stretcher after each call and wipe down the straps, but I didn’t notice a great change in people’s habits.  

We didn’t get a whole of Corona training.  We had to watch a fifteen minute or so video on-line  that was pretty boring. That said, every year we get airborne pathogen training and there is nothing in there that is different with Corona.

Talking with others, the lines I heard the most were “The flu has killed more people this year than corona,” and “It’ll just be like getting a cold, I’m not afraid.”

My younger co-workers have no fear, which I also didn’t when I was their age.  The older medics, like myself, are more concerned. At 61, I am according to some sources, supposed to be staying at home to protect myself.

We also received the CDC guidance.

Interim Guidance for Emergency Medical Services (EMS) Systems

We just received this notice today from the state:

New guidelines from the CDC recommend that instead of N95 surgical masks, health care workers can use looser-fitting face masks to shield themselves from contracting the coronavirus, a change prompted by an ongoing shortage of the N95 respirators. The virus is primarily spread by droplets, and the agency is narrowing its recommendation for the use of N95 masks to workers dealing with severely ill patients.

So the change to the lessor quality of protection is due to a shortage, not to safety.

A friend of mine (not much younger than me)  told me he was worried we are going to run out of masks.  He said his wife told him if that is the case, she will forbid him from going to work.  But honey, he said, I have to work. He is the breadwinner and I don’t think he has cash reserves. I am worried that in our country people will hide their sickness because they can’t afford to miss a paycheck.  

Lebron James the basketball great said the other day “I aint playing if the fans aren’t allowed to attend the games.”  He says that’s who he plays for. I don’t expect him to be a public health expert to understand the threat of corona or the importance or slowing the transmissions.  I’m watching a sports show on the TV now and they are talking about how much money it will cost the NBA owners if they have to cancel or put on games without fans in the stands.  I understand the owners and players may lose some money, but we are talking ants to giants here, sports to global wellness. The economic cost to the world and all people will be much greater if this virus is not kept under some type of management.  Not to mention the human cost. We may only get a cold, but if it gets passed to enough older people, many of them will die who otherwise would not have. We need to protect our frailest citizens. That outweighs watching the NBA playoffs, and I am a basketball fan.  Go Celtics!

I have heard some employees from our company who were exposed to COVID-19 out west have been placed in self-isolation.  I was reading what self-isolation is about, and while each article is different, they share some common themes.

You have to stay in your house.  If you order pizza, the delivery man has to leave it on your doorstep.  You are not supposed to go outside (leave your property). You should stay in one room. Ideally with your own bathroom.  You shouldn’t go for a run in the woods. You might give corona to the raccoons.  

Again I ponder.  What do the homeless do? 

I read we should be using credit cards rather than passing bills which may contain the virus.

I usually carry a few spare dollars to hand out to people in need.  Should I stop?  I handed out some dollars on Monday.  I hope I didn’t pass any germs.

I’m back at work on Friday.

We’ll see what the day brings.

***

1. My daughter also had her sixth grade basketball state championship games this weekend cancelled.  They had made it to the semi-finals. All high school sports championship tournaments were also cancelled.  Curiously the UCONN basketball team traveled out-of-state to play in a capacity arena and there is no indication they won’t go ahead and play in the upcoming March Madness, including likely hosting games on their campus.  We’ll see what happens when public health meets NCAA dollars.
2. I’m on the hook for a night’s hotel stay.  My trip was being paid for by the federal government, but I had to use my credit card to guarantee the reservation, and would only get paid back later when I submitted the receipt.  I was smart enough to get insurance on the airline ticket, but I had to tolerate three hours in the phone line waiting for an operator due to all the corona flight cancels, “Celebrate,” "Hello, "It’s Me," and Fleetwood Mac’s “Gypsy” and about four other easy listening songs on a loop that I must have heard 20 times before a blessed human voice finally came on (she was very nice when I finally got to talk with her).
3. I think in those areas where police, fire and the ambulance all respond to 911s at nursing homes, maybe they should limit the response to just the ambulance.  It is rare that anyone beyond the ambulance crew is needed, and surely two people entering is safer than eight for both the patients and the responders.

Corona Cough

 I may have mentioned before, I have a bad chronic cough. I have had it all my life. I can go all day without coughing, and then I get a hunk of phlegm on the back of my throat and I just have to cough, and often it takes me five or six coughs to get it clear before I am fine again. These are not little dainty coughs. These are earth-shaking put your hands down on the counter, lean over and hope you don’t pass out coughs.

It is rare that I don't have someone come over and ask me politely “Are you all right?”

That was before Corona.

I am at work at the hospital and headed to lunch at noontime. In the elevator, I feel a cough coming on. Just before the door closes, a leg sticks through, and it reopens to admit a young nurse. I smile at her, doing my best to hold my cough in. It is only two floors. I hold my breath and then I hold the door for her and as soon as she is by me, I bolt to the corner of the hallway and cough into my arm, and for a moment, I am alright. A close one.

The cafeteria is crowded like a watering hole on a scorching day. I make my way through the throngs to the salad bar, still feeling a bit of an itch in my throat. I get a plastic bin, and no sooner have I put two leaves of lettuce in it, than I feel the urge to cough come roaring back. I drop the salad tongs and retreat to the coffee machines, and try to collect myself. But no matter how hard I fight it. I can’t hold it in. I cough once hard into my shoulder.

The cafeteria falls quiet.

Ears perk.

It is like a herd of deer has lifted their heads. Not a movement.

Could a wolf be about?

I move quickly several steps to my right, and try to hide behind a man carrying a tray with two cheeseburgers and a large order of fries on it. I cough again. There is a fluttering through the room. The cheeseburger man bursts forward quickly, and I am left naked in the open. Heads swivel, searching for the perpetrator. Two women eye me. One whispers to the other. I see a man point toward me, eyes narrowing. They are all focusing on me. I fear someone will shout “There’s he is! There’s the cougher! He's going to kill us all! Stone him! Stone him!”

If I take another breath, I will cough uncontrollably.  My eyes will water, my face turn purple!  I can't let that happen.   I still hold the salad bin in my hand. I calculate if I can make it to the register. Not a chance. The lines are too long. Still holding my breath, I turn, put the bin with the two leaves of lettuce in the garbage and flee back out the cafeteria entrance. I flee down the hall, then into the elevator, which thankfully is empty. I go back down the two floors to the basement, and flee down more long halls until I am safe in my basement office where I sit in my chair trembling.

Oh, man. 

Devil Around

 

Police in Holyoke, Massachusetts are warning about a new heroin mixture that may not respond to naloxone,  It allegedly produces violent reactions in its victims. The mixture contains the synthetic cannaboid MDMB-4en-PINACA .

Holyoke police warn about new drug mixed into heroin that causes ‘violent’ behavior, may not respond to Narcan “

The article is misleading in its assertions about the possible ineffectiveness of Narcan. Narcan may not cure this overdose, but if the person is violent, they do not need Narcan. If they were unresponsive and received Narcan and are now violent, then they responded to the Narcan. Narcan works on opioids, not on cannabinoids. Cannabinoids usually do not cause respiratory depression or respiratory arrest, which is the indication to use Narcan.

Here in Hartford, dealers have been adding PCP, among other substances to the heroin/fentanyl they sell. We have seen people with violent reactions post Narcan that could be due either to their annoyance at being suddenly put into withdrawal or it could be due to other devilish substances that are now unleashed now that the patient is conscious.  More typically, the heroin users I have had who overdosed and also had PCP onboard, returned to maintenance breathing, but were often catatonic. One of the users called the drug mind-fuck. Others have complained of racing hearts -- we’ve seen heart rates in the 160s-200s, as well as the bizarre behavior associated with PCP and other disassociative and mild altering drugs.

Instead of treating these patients with Narcan, we use Versed or Ativan, benzodiazapines that sedate the patient.  We get a lot of experience with this as PCP overdoses, at least in the north end of Hartford, are more prevalent than heroin.

Two points behind all of this.

Naloxone works on opioid overdoses.  There has yet to be confirmed evidence of an opioid that does not respond to naloxone.

There are some nasty substances being added to heroin.

What do we do about it?

I think it is time a city in the United States provided medical grade heroin to users in supervised injection sites, and follow how these users do over the course of a year. How many die? How many developed endocarditis or skin abscesses?  How many are arrested for violent behavior or other crimes?   How many got into rehab?

No only our our fellow Americans dying in unacceptable numbers, they are being poisoned by the additives dealers are adulterating their opioids with.

Medicinal grade heroin has worked in England. We should try it here.

Legal Heroin Prescriptions: The 'British System' You Never Knew Existed