Rick James, David Crosby and Mike Pence

 A large man stands handcuffed, surrounded by six police officers by the side of the road.  Nearby two citizens have their iPhones out recording.  The man does not mince his words.  “I’m going to kill all of you.  I hate cops.  I’m going to eat you.  You’re gonna be in my belly.”

It is clear that this man is having a manic episode.  He will not shut up.  On and on, he goes about the horrible things he’s going to do to.  “Give me back my guns!  I already took my drugs!  Now let me go!”

The guns it seems are two plastic toys with flashlights taped to them with masking tape.  “I’m going to kill every motherfucking last one of you.”

I walk up to an officer to get the story.  “Have you dealt with him before?” she asks.  “This is not unusual for him.”

I don’t recognize him, but he is not unfamiliar at the same time.

I nod and then approach him.

“Look at what they doing to me,” he says.  “I’m going to kill them and eat them!”

“You like drugs?” I say.  “How about  Ativan?  I’m going to give you some benzos.  They’ll make you feel a whole better.”

“I already had my drugs!”

“More the merrier,” I say.  “I give you a shot in the leg, tiny needle, no pain.  You’ll feel better and we can get you out of these cuffs.”

“Take me to the hospital,” he says.  “But my guns are coming to.”

“We’ll put them in your bag.”

He takes the shot – I give him 10 of Versed in his thigh.  He takes it like a champ.  It takes a little while, with pushing and prodding, to get him on the stretcher, and he keeps jabbering away.  We get his two bags and put them on the back of the stretcher. 

I ask the cop to take his cuffs off.  “He’s agreed to behave, isn’t that right?”

The cop looks dubious, but I don’t want this guy lying on his wrists.  I am counting on the Versed and my own powers of persuasion to keep him distracted, and keep him from wrecking any havoc on me.

The cuffs come off and he doesn’t take a swing, though he keeps up the verbal barrage about how he hates cops and will come back and kill them all for his dinner.

He doesn’t stop talking in the ambulance, but at least he is not aggressive towards me.

“You know who I am,” he says, as he reaches into his bag and pulls out a long wig of purple hair, which he sets on his head.

“You’re Rick James!” I say, referencing the 70’s funk star, who he has become the spitting image of.  “Super Freak, Super Freak,” I sing.

“No, man I am death.  D-E-A-T-H.  You know who lives in my wrist?“  He points to a large scar.

“Tell me.”

“Jesus Christ.  He lives in my wrist.  He comes and smokes weed with me in the mirror at night.”

“Interesting,” I say.

“You look stressed.”

“Well, all this COVID stuff has me a bit drained.”

“You know where COVID came from?”

“Wuhan, China?’

“No, it came from my right eye ball.  I set it loose on the world cause I’m death.  D-E-A-T-H.”

“Are you planning to summon it back to your eyeball?”

“No, I got a girl staying there right now.  My soul sister.  I’m getting mine.” He punches his fist against his hand several time rapidly.  “You follow?” 

“I think so.”

“We all got soul sisters in our eyes.  You, too!  Don’t tell your wife about her.”  He makes that motion with his fist and hand again.  “Get yours.”

“Maybe you could make some room in the other eyeball and get that corona back in there somehow.”

“You look stressed,” he says, again.  “You should quit this job.  Go buy yourself some weed, smoke it in the mirror and talk to Jesus Christ.  Then go get yourself a good job.  Go work at Stop and Shop.  Take the load off, you’re old.

He ends up four pointed in the psychiatric wing.

When I punch out, my partner says if it works out for me at Stop and Shop, maybe I can get him a job, too.

***

I am feeling old.  The COVID quarantine with the swimming pool and gyms closed, my workout routines have gone to seed.  I find myself sitting in front of the TV most nights, and when I watch TV I need to be eating.  I have gone from raw vegetables and berries to bags of potato chips and Oreos.  My pants are starting to feel tight.  I do exercise with my daughter.  We film part of a one on one game we play.  I realize she is getting by me not just because as a twelve year old, she is quicker me than me, she is getting by me because I am slow.

I am an old man with a bent back and a shuffle to his step it seems.  A friend at the hospital tells me with my lack of a haircut, my thinning hair on top, and my corona mustache, I look like David Crosby.  I don’t think he means this in a good way.

***

I waiver back and forth from I already had COVID-19 (either I had it in the end of January/early February when I was so sick or I got it on the job and didn’t have any symptoms other than the general symptoms of being 61 or I had it and was completely asymptomatic—how could I not get it doing the calls I am doing with the PPE I am wearing if this thing is infectious at all) to it is only something people in nursing homes, prisons and group homes with major medical problems need to worry about to being concerned the ache in my bones, the slight sore throat, the cough a little worse than normal, are the beginning of the end for me.  Maybe I will be one of the ones the germ sinks its spikes into as it climbs down into my lungs and makes waste of me.

I’m not sleeping so well.  I am trying to eat better and work out more, but like tonight when I came home, I was tired and outside it was cold and windy and damp.  I ended up just taking the trash out.  I had several trips with it because tomorrow the garbage truck comes.  That was my work-out for the day.

***

I am watching TV now and trying to make sense of what I’m seeing.  Today the President ordered meatpacking plants ridden with the virus to re-open.  The Vice-President visited a hospital and wouldn’t wear a mask.  The Dow Jones was up another 532 points.  You would think this thing was over, that it was all going to be sucked back up into D-E-A-T-H's eye.

Something doesn’t seem right.

 

Gas Mask

Sitting in my office earlier today watching ambulances bring in COVID patients, I saw one responder in a yellow haz mat suit with a gas mask on. The PPE some services are providing continues to be upgraded. It may be expensive, but when compared to the cost of human life, not to mention lost workforce, it is work it.

Connecticut has seen hospitalizations decline for 8 straight days now. Our governor, who has handled things quite responsibly (despite my annoyance at his advocating shutting down the basketball hoops), is planning to start opening the state on May 20 with the first of four phases, the first phase to include outdoor restaurants, parks, hair and nail salons, retails stores, and offices. 

These are the Connecticut businesses that can reopen on May 20 with coronavirus safety measures in place

Still, I am uneasy about calling this thing over by a long shot. The troubling thing I have noticed is that COVID has its hot spots. We will get several from the same house or group home, and certainly many from certain nursing homes, but as soon as one group home or nursing home slows down on sending patients, another address will pop up for the first time and will follow with a cluster of patients.

I mentioned a few weeks ago about deaths in one nursing home in Connecticut. Well, it turns out those number were low. The Hartford Courant now reports 43 of 146 patients died of corona virus in Kimberly Hall North, a building I have been in. It looks just like any other average nursing home.

At Kimberly Hall North in Windsor, at least 43 people have died during the coronavirus crisis, making it one of hardest hit nursing homes in the country

As we relax some social distancing guidelines, we have to be careful do not underestimate COVID-19s ability to sudden turn from an ember into a four-alarm fire.

***

Meanwhile,  the normally reserved Dr. Anthony Fauci, seems excited about about the drug remdesivir and the possibility of having a vaccine ready and produced in millions of doses by January, despite the bypassing of normal safety measures.

Fauci optimistic about remdesivir as treatment for COVID-19 

Dr. Fauci Is Optimistic That a Coronavirus Vaccine Could be Available by January 2021

I mentioned before I was reading a book about the Spanish flu pandemic in 1918.  Vaccines were produced and distributed back then to great fanfare.  The problem was they didn't work.  Let's hope history doesn't repeat itself.

Spanish Influenza Pandemic and Vaccines

 

 

Good Times Again

 

States are starting to open up their economies. Here in Connecticut, hospitalizations have dropped for five days in a row. There is talk of major league baseball planning to play this summer. The stock market is booming again in anticipation that good times will be here again.

Some public health ninnies are warning this is going to be a disaster. Based on the reopening reports, the Washington University COVID-19 model just upgraded its national death forecast to 74,073 from 67,641. In Connecticut, the deaths have been marked up from 3,006 to 3,340.

United States of America

As much as I want the economy and sports to be reopened (in a smart way), I do see where this is heading. I have used the analogy of the shark movie before. A shark is terrorizing a community.

They catch the shark and everyone is thrilled, but the movie is only an half an hour in with another hour to go. The people flood back to the beach and dive in the waters, but the big fish is still out there, and the waters will soon turn blood red.

It is my understanding that in order to do this the right way. You need to not only have the first wave beaten down-I’m not talking about getting past the peak, but two weeks of steady decline in hospitalizations—and you need the ability to test your citizens. You test them regularly and repeatedly and when someone tests positive, they need to be isolated and their contacts traced.

Nobel Prize-winning economist Paul Romer says for the US to return to normal by the summer every person must be tested — at a cost of $100 billion

The Cold Calculations America's Leaders Will Have to Make Before Reopening

Otherwise this thing is going to come raging back. Think about this. Estimates of how many people have already been infected range from ballpark figures of 2% to 15% to maybe even greater. Let’s say 30% have been infected with many being asymptomatic. If that number produces 60,000 deaths, what is going to happen when the other 70% get infected? This will likely happen if social distancing is dropped and no vaccine is available. And while there have been reports of many vaccines being trialed, to date no one has ever created a vaccine for a corona virus.
Without testing, asymptomatic first responders could easily spread the virus to every house and nursing home they respond to. We should have been among the first people ever tested, yet unless we have had symptoms, most of us haven’t, we do not qualify for testing. In the meantime asymptomatic celebrities and sports stars have easy access to testing.

I know they are working on this, but a few more weeks or months of this quarantine may be the best course. Just think how bad it would be if/when a second wave hits and we have to do this all over again from the beginning.

In addition to the widespread availability of testing, we also have to have adequate PPE. The CDC continues to say that it is okay to use surgical face masks when treating patients with COVID-19 and the only reason it is okay is for issues of supply.  Health care workers are asked to sacrifice their individual safety for the greater good of having PPE available for more dangerous procedures. We may all accept that, but the fact remains that many of us are working with masks that do not protect us and the government acknowledges this. 

Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings

Face mask shortage prompts CDC to loosen coronavirus guidance

While EMS protocols say we should reserve the N95 for aerosolizing procedures, in the infection control kits we are given each morning there are N95 masks, and if I want to put one on when I have a patient with known COVID-19 or suspected, no one has given me an issue with wearing one.

That apparently is not so everywhere.

Nurses Placed On Paid Leave After Requesting N95 Masks When Treating COVID-19 Patients

Hospitals muzzle doctors and nurses on PPE, COVID-19 cases

Widely Used Surgical Masks Are Putting Health Care Workers At Serious Risk

Before we fully open up the economy, we need to see that our health care workers are adequately protected should a second wave emerge.

Peace to all.

Battle Royal

 He is naked in the nursing home hallway, rolling over and over.  We manage to get a sheet under him and lift him up onto our stretcher.  His room air pulse saturation is 74--severely hypoxic.  The nurse, who told us he was COVID positive, said he walks around the wing and can hold a normal conversation.  He is all gibberish this morning, talking in tongues that don’t sound human.  I put a nonrebreather mask on him and then place a surgical mask over it.  He tries to grab the mask, but I am able to keep his hands away.  In the back of the ambulance, he tries again to take the mask and oxygen off.  I keep telling him to cut it out and to stop, but he is too far gone to understand me. I take his arms and put both them at his sides, underneath the middle seat belt.  When I move toward the radio to call the hospital, his arms get loose and  he knocks his mask off again.  When I try to  replace it on his face, he grabs my wrist and starts pulling me towards him.  He is strong.  He has a death grip on my wrist.  He grabs my gown and shirt with his other hand and suddenly we are wrestling.  His mask is off and respiratory droplets are shooting out of his mouth right at me.  Even though I have an N95 mask on and a fogged up face shield over that, I am stressed by this turn of events.  COVID -19 has transformed him into Hellboy and he is spitting respiratory droplets at me like a spitfire plane strafing a beach.  I manage to put my knee on his side and and swing my right arm loose.  He still has me by the wrist.  My yellow gown is torn and pulled off my shoulder.  I am finally able to unpry his fingers off my wrist and then I sit back on the seat out of his reach.  The mask is off his face.  He mutters gibberish in his own world.  In the ER he will be sedated, intubated and shipped to the ICU. 

Normally after a call, I try to clear the hospital as quickly as I can, but not after this one.  I wash my hands multiple times, and then sit in an armchair in the empty  EMS room.  I write my run form, but instead of getting right up, I sit there a few minutes more.  And then I put my mask back on and head out to the ambulance.

I am finding these constant COVID calls draining.

New Brand on the Street

 When I work the city, I drive Park Street and look for users I know. How are they making out? Inez, who I see in front of El Mercado, has a mask on. She comes over when we pull to the curb. I give her an orange and a couple dollars. She says she is trying to keep safe. I tell her while she needs to keep social distance, she still needs to have people around when she uses. She says she understands.

Park Street seems more deserted these days. Many of the people are wearing masks, but not all. When I drive back down the street that afternoon, I see Inez again and she no longer has her mask on and is hanging with two dudes in hoodies.

I see my friend Chloe who works as a prostitute. She has a cough and her voice is hoarse. Business has dried up for her, but she says she has a man looking out for her. I see him standing in a doorway down from us beckoning to her. She says some of the guys get nervous when she is seen talking to the ambulance people. If you want to get off the street, I say, and away from all this, get in the back. We’ll take you to the hospital. Tell them you want detox. Tell them you are afraid you are going to kill yourself out here. I know, I should, she says, but not today. I’m not ready. She looks back over her shoulder at the man watching her. I wave to him, but he doesn’t wave back. I give her my package of pretzel brown sugar cinnamon Pop Tarts, an apple I got from the hospital EMS room and a bottle of Gatorade, along with five bucks. Stay safe, I say.

We get called for chest pain at a halfway house. The man sitting on the steps wants to get a Corona test because some guys in the house have it and he is worried he may have it to. I tell him we will take him in and get his chest pain (now gone) looked at, but they will only test him for COVID if they admit him. He declines transport.

Another user comes up to me later in the day and asks me the symptoms of Corona. He has a cough and chest pain. He wants me to take his temperature, but I tell him we don’t carry thermometers, which is true. I offer to take him to the hospital, but he says, no, that’s okay.

It is a cold windy day. Up by the Fastrack bus stop, there must be fifteen users all sitting together sheltering, not one of them has a mask on.

On my phone, when I check my email, I see there is another overdose spike alert in New Haven County to our south.

On the north side of town, one of our ambulances is sent for an unresponsive. A half hour later on the radio, I hear them call the hospital to speak with a doctor. They have been working the young man found in asystole (flatline) with drug paraphernalia on scene for over twenty minutes and want permission to cease the resuscitation and presume him dead. It is granted.

A medic in Waterbury, sends me a picture of a new heroin bag he found there at an overdose scene.

Corona Virus.

A Good Day

 Today was a good day. I went into work for a couple hours and was surprised I only had to make one EMS notification of a COVID-positive patient.

Around noon my daughters and I met another father and his daughter. We hit softballs on a nearby field, all the while complying with the town gathering limit of five people and maintaining social distance of six feet at all times. We had a pitcher, a batter, two outfielders, a shortstop, and two buckets of softballs

It was a beautiful day and played for two hours under a clouless blue sky. The fathers, both in their sixties, played like young men and the girls hit and fielded as if they hadn’t missed the game at all this last month.

In the early evening, after a nap, my daughter and I played basketball in our driveway. This week, a couple whose kids had grown up and moved away, gave my daughter their children's old basketball hoop, so she can shoot baskets everyday and the town can’t take our rim down.

I went to the supermarket and it was nearly empty of people and the shelves were stocked of most items I wanted. While there was no toilet paper and still no flour, I did snag some paper towels, and some pork chops and fresh fish, and got lots of snacks for the girls and me,

Tonight, we watched a movie together, and while it was kind of dumb and a chick flick, the three ladies of the house liked it, and I was just glad to be in their presence.

The day’s stare COVID stats came out and for the first time, hospitalizations were down in all three major counties. There were another 98 deaths, but the deaths are a lagging indicator, and while tragic, I would expect the numbers to go  down in the coming days as it looks like we flattened the curve and are on the downwards side at least of this wave. I also had more good news about a friend of mine who has been hospitalized for several weeks with COVID, and is doing much better and hopefully will be released soon.

I did read a depressing article about how many scientists privately doubt we will ever find a vaccine for the corona virus as we have yet to ever find a vaccine for any corona virus, and that it will be with us forever and we may never develop strong immunity to it. I tried not to dwell on it.

I lived today fully and am thankful for that opportunity.

 

Incredible Hulk

 

Today was all COVID. What came in as a rectal bleed blossomed into a story of an intense cough, abdominal pain, several days of diarrhea that now had blood in it, and a history of exposure to a COVID positive person. When we arrived on scene, before entering the patient's apartment, I reached in our PPE bag and came out with the new space suits that I had so admired another service wearing. Unfortunately at six eight with size 14 boots, I did a number on the suit, tearing it in multiple places like I was the incredible hulk (I use small letters out of respect to the read dude). I ended up having to revert to the two yellow napkin gowns double tied to cover my length.

The next call came in as an asthma, but was really a person with clear lungs, shortness of breath, tachycardia and fever with, that’s right, a relative who is COVID positive. While the patient said she had little contact with the COVID positive relative. “I don’t go in the door,” the woman said to me “I just let the kids in so she can watch them while I work.”

I just shook my head.

Both patients had horrible hacking coughs.

The other two calls were both out-of-town transfers taking COVID positive patients out of acute care hospitals, one to the group home he came from where several others were also COVID positive and the last to a new COVID-19 only nursing home that just opened up over an hour’s drive away. I understand the need for the COVID-only nursing home, but a number of us have been sent on these long trips, where we have to sit alone in the back of the ambulance in a clearly confined space with coughing patients even though both patient and EMT are fully masked. I wish some of these homes were closer to us. I have the exhaust fan and I sit in the captain’s chair behind the patient and try to make myself as small as possible. I wear my N95 mask and a surgical mask over it. Not crazy about that part of the job.

On the way back from the transfers I read more COVID news stories. One was about how schools might be when they start back. The author suggested they would start with the younger children and have no more than 12 to a class. Maybe have the kids go on rotating days or mornings for some, afternoons for others. The author was pretty certain there would be no sports, not for quite awhile. Not crazy about that either.

I don’t understand with all the death and uncertainty, why the stock market is rising so much. I see much pain, physical and economic ahead for many Americans.

One nice thing about today, McDonalds gave us all free breakfasts when we went through the drive through. What a kind surprise! I had their new Chicken McGriddle and it hit the spot.

When we came in from the road at the end of the shift, in operations they had a box with jelly bean packages of the good jelly beans. The packages said, “Thank you” on them. Another appreciated touch.

They also have a sign there when we come into work that says, “Superheros enter here.”

It’s corny, but it makes us laugh and feel a little lighter about our day, so I don’t think anyone is going to be taking it down for awhile.

It is still a long road ahead of us.

Another 125 dead in Connecticut.

PPR When Seconds Matter

 

“Are there circumstances where you treat a patient before you put on your full PPE?”

This question provoked great debate with some saying you absolutely have to put on your full PPE in this age of COVID.

My take on it is it would be great if you could, but it is not always so easy.

Here is a call I did last week.

I am in a fly car driving down the road when I am dispatched to an overdose outside an apartment complex. I hit my lights and sirens on and within two minutes I am pulling to a stop. I can see the man on the lawn being held up by another man. The man is in the frog position, a common position we find heroin overdoses in. His knees are forward, his body bent back over the legs, but his torso bent forward. The man trying to get him up, has lifted his torso up, but now it bends backwards. I get out of the car, run around the back, lift up the rear hatchback, grab my house bag, the blue isolation bag and the heart monitor. I approach the man, and setting my gear down, I reach into my back pocket and take out my latex gloves, which I apply.

The man is cyanotic and is not breathing, but he has a carotid pulse. “Heroin?” I say to the man holding him up. He just shrugs as if to say, “Yeah, I guess you could say so, but I’m not the one saying it is so.”

Now I have already made contact with the patient before putting on my isolation gown. The problem with the isolation gown is it takes a little bit to put on. I have to either first take off my outer jacket or else try to squeeze my arms through the thin sleeves, likely tearing them. I also have to tie the gown, which is open in the back. Our gowns tie only in the back and I can only tie them if I am looking in a mirror or have someone else to tie them for me. I suppose I could ask the guy holding his buddy up, but I think he pretty much has his hands full.

I am already wearing my surgical mask, which I keep looped on my ears and my goggles which I wear always nowadays.

My choice. Put on my gown or take out my narcan and my ambu bag and start treating him. He is after all not breathing, and his brain cells are dying and he is at high risk for going into cardiac arrest. If I use the ambu bag, I definitely have to have on my gown and also switch my mask to a N95 instead of the surgical mask.

I quickly open up my house bag, take out my med pouch, unzip it and take out a vial of narcan, screw it into the bristojet, then attach a needle, which I plunge into his thigh, giving him 1 mg of naloxone.

Only then do I put on my gown, without tying it. It soon starts slipping off my shoulders. What am I going to do?  Not much I can beside trying to pull it back up on my shoulders.  I get my ambu bag out and start breathing for him.

By the time the ambulance arrives, he has started breathing again on his own, and shortly after now alert, denies he did any drugs at all, despite the needle we find in his pocket.

So did I do right?  Some will say yes, some will say no, some will say you had to be here.

I made my choice that he needed to be saved right now, and that outweighed the small risk to me of not having all my PPE on.

If you think that we have to protect ourselves at all costs, then my answer would be then we have no business being out here with the ineffective PPE we are being given unless our services are giving us space suits.

I did find some backing to my decision in the recent International Liaison Committee on Resuscitation (ILCOR), position paper, which often forms the basis for future AHA Recommendations.

The issue for them is not a person in respiratory arrest from opioids, but a patient in possible ventricular tachycardia.

Here’s what they had to say.

 

Consensus on Science with Treatment Recommendations (CoSTR) COVID-19 infection risk to rescuers from patients in cardiac arrest

Treatment Recommendations

•We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence)

•We suggest that in the current COVID-19 pandemic lay rescuers consider chest compressions and public access defibrillation (good practice statement).

•We suggest that in the current COVID-19 pandemic, lay rescuers who are willing, trained and able to do so, consider providing rescue breaths to infants and children in addition to chest compressions (good practice statement).

•We suggest that in the current COVID-19 pandemic, healthcare professionals should use personal protective equipment for aerosol generating procedures during resuscitation (weak recommendation, very low certainty evidence).

•We suggest it may be reasonable for healthcare providers to consider defibrillation before donning personal protective equipment for aerosol generating procedures in situations where the provider assesses the benefits may exceed the risks (good practice statement).

Justification and Evidence to Decision Framework Highlights

•Given the potential for defibrillation within the first few minutes of cardiac arrest to achieve a sustained return of spontaneous circulation and uncertainty of the likelihood of defibrillation generating an aerosol, we suggest healthcare providers consider the risks versus benefits of attempting defibrillation prior to donning personal protective equipment for aerosol generating procedures.

• The time taken for a team to don personal protective equipment may be up to 5-minutes, although individuals may don equipment in around one-minute(Abrahamson 2006 R3, Watson 2008 333-8). However, once donned we identified evidence that there is a risk of mask slippage during chest compression delivery rendering the protective equipment less effective.

 

Peace and safety to all.

Scenarios

I am as pessimistic as I have been.

Here is my worst case scenario:

COVID-19 turns out to be as infectious as the common cold and if people develop antibodies to it, the antibodies only last a few months.

People who are asymptomatic turn out to be the biggest spreaders of the disease. Even those who develop symptoms spread it during its incubation period.

Each time you get COVID, it leaves you weaker physically. You not only never recover fully, you are still at risk of getting it again, and again.

COVID-19 mutates to a stronger deadlier germ that targets younger people in its second wave.

States relax social distancing too much, unleashing COVID again to not just physical but psychological detriment.

Other states while holding social restrictions to tight fail to find thoughtful ways to reopen the land in ways that can both protect people and get some semblance of an economy and more normal life running again.

I get it and die.

And so does my wife.

My children are orphaned.

***

Here is my best case scenario:

I already had COVID in late January/early February and survived it. My family has also been exposed and were largely asymptomatic.

Once you get it, you can never get it again.

There are far more asymptomatic people out there than any study suggests.

COVID-19 will mutate to a milder form and will be no worse than the seasonal flu.

States will gradually relax their social distancing and if it remerges, it will only be in minor manageable ways.

Our economy will come back and people will get jobs again, and this will all just be a blip in our memories.

We will use its lessons to better prepare for pandemics in the future.

As the Black Plague gave way to the renaissance, so will COVID give way to innovation and a better life for all.

***

The New York Times had another article about how corona may have been here much earlier than previously reported.  This helps my argument that I might have already had it.

Hidden Outbreaks Spread Through U.S. Cities Far Earlier Than Americans Knew, Estimates Say

The CDC Director backed off his second wave comments a bit after the White House likely castigated him.

CDC Director Clarifies Concerns Over Potential Second Wave Of Coronavirus

Dr. Fauci weighs in:

Dr. Anthony Fauci: ‘We Will Have Coronavirus In The Fall’

Here's an article on how long people might be contagious if they have no symptoms:

How Long Can Asymptomatic Coronavirus Carriers Infect Others?

Another article targeted to this 61 year old.

Coronavirus: Anyone over 60 is 'high risk', scientists warn

Stay well all. 

OD Deaths Versus COVID Deaths

 Early on, I wondered when this was all over, if we would say, we did all this disruption and in the end, fewer people died of COVID than accidental overdoses in our state.

Well, this week COVID has blown past substance use deaths. As of yesterday there were 1554 deaths in Connecticut is just a little over one month versus 1200 OD deaths in a year.  Nationwide COVID deaths at 47, 034 still lag annual OD deaths at 67,000, though they will likely catch up and surpass.  I don’t mean to compare loss of life from one to the other. They are both tragic.

I also wonder how many more deaths there would have been in our state had our governor not put into place social distancing and business and park closures. Even with that Connecticut is one of the hardest hit states in the nation both in terms of sheer death numbers (6th) and the high mortality rate (6.9%-2nd). Currently our cases are doubling every 11 days.

Connecticut COVID-19 Statistics

United States COVID-19 Statistics

None of this means we should stop paying attention to substance use deaths, which may likely accelerate due to the COVID epidemic for the following reasons

1. Decrease in out-reach services that have been shuttered or have reduced hours.

2. Decreased availability of Naloxone.

3. Disruption in drug supply lines leading to bad mixtures or people buying from unfamiliar dealers

4. Increased stress can lead to increased substance usage.

5. Isolation can lead to people using alone without a rescue partner.

6. People being released early from jail with decreased tolerance.

7. People who are COVID positive may have decreased respiratory reserves making them less likely to survive an overdose.

8. Loss of work and health insurance can lead to substandard care or failure to seek care.

9. Stimulus checks could cause binge drug use leading to fatal overdose.

10. EMS protocols that out of COVID precautions, now(in some areas)  forbid or restrict use of bag-valve mask ventilation to assist people who are not breathing or ventilating ineffectively.

One of my jobs is to read every day the Statewide EMS overdose reports that are called in daily to our poison control center. The stories continue to be heartbreaking. Patient released from jail, found dead the next day with syringe in arm. Child finds parent dead in bathroom, doing CPR on EMS arrival. Young man found dead in hotel with empty heroin bags around him. Homeless person and known heroin user found dead in vacant building. Young woman found dead in upstairs bedroom by parents when they came in to say goodnight.

Whether a death in a nursing home, in an ICU or behind a building, we are family in Connecticut and in America.

We are all in this together.

Easter

I worked the city today, and after a slow start, banged out 5 calls, and then they sent us in.  Volume is down,  plus today, as a holiday, we get double time and a half.  I could have stayed at the base and clocked the last three hours, but I wanted to get home to my family.  This Easter morning, the Easter bunny did not come to my house.  Every year I buy candy and baskets in advance, and hide the candy in the early hours of the morning before heading out to work.  It slipped my mind this year.  Bad Dad.  During the day, I did however, concoct a plan, to resurrect the Bunny's reputation.  I went to the Dollar Store during a brief lull in the action  and bought candy, two baskets and some fake grass.  Before I got home, I assembled the baskets, and then left them outside by the garage door.  

"Hey, did you guys not go outside?" I asked my daughters when I got home.  The youngest was in the basement watching TV, the oldest in her room, studying.

"No," they both said, sheepishly, knowing I encourage them to get fresh air

"You ought to.  There is something out there for you."

It took me awhile to get them out to look, but they were both happy when they came back inside with their Easter baskets.

"You guys thought the Easter Bunny forgot you, didn't you?" I said.  "I was driving home and outside half the houses there were Easter baskets.  There's a pandemic going on.  The Easter bunny can't come in people's houses.  He's like the pizza delivery guy.  He has to leave his deliveries outside."

"What about me?" my wife asked.

"What about you?  When I went to work, there was a new car in the driveway with an Easter ribbon on it.  The keys were in the car and it was running. "

"What?"

"Someone must have stole it.  Maybe next year.  You snooze, you lose.  You can't lose faith in the Easter Bunny.  You've gotta be up at the crack of dawn."

***

Here the calls I did today.

An elderly woman with a cough and shortness of breath over the last two days.  Her room air SAT was 88.  We donned our isolation garb and put a mask on her.  Here's what my gown looked like after I put it on.  Both arms ripped.  It was cold and I kept my jacket on, which was a mistake because the gown fits better when I don't wear the jacket.  Not that it fits at all.  I'm glad we're not in the middle of winter.

A young woman with chest pain when she breathes, nausea, and vomiting.  Mask for her, gown for me, but she kept taking her mask off to vomit.  I gave her some Zofran, but it didn't seem to help.  Her sister was angry at us that we wouldn't give her her own mask or let her ride with her sister in the ambulance.  No family in the ambulances we said, and no visitors at the hospital.  And we can't hand out masks to the public because we are getting short ourselves.

An older woman who tripped on a curb and smashed her face.  Even though she likely broke her nose, she wanted no part of going to the hospital.  No, thank you.

A young man with homicidal thoughts, who was cooperative with us, but agitated. He wasn't specific about why he wanted to hurt people or who he wanted to hurt, he just said the voices were telling him to do some destruction.

An older man from a hospital COVID unit going to a COVID nursing home after a two week stay in the hospital.  More isolation gear.  The nursing home also took our temperatures (one of the hospitals does the same each time we enter) and made us wear hair nets before we could take the elevator up to the COVID floors.

Again, I ask the question, after we doff our "contaminated" yellow napkin gowns and carefully place them in bio-hazard bins, I wonder what it is about my long legs and boots that provides them with a contamination free zone.  I don't take them off after each call and put them in a bio-hazard bag.  (Of note, paramedics from a neighboring suburban town who we interface with when we respond to that town, have started wearing the full body alien suits.)

***

The hospitals up here are still half empty, the hospital overflow tents not yet in use.  

***

I was thrilled to go home early.  After I stripped to my underwear in the laundry room and took a long hot soapy shower, then changed into my jeans, I wanted to play some basketball with my daughter, but I was suddenly hit by a wave of tiredness.  Both my wife and my daughters told me I looked terrible, so I went in the bedroom and lay down without moving for nearly two hours.  I took my temperature when I got up.  It was 98.6.  My heart rate was 56 and my pulse sat (after taking a deep breath, rose from 94 to 98).  I have been coughing to beat the band today, and while I have a horrible chronic cough, I confess, it has me a bit worried.  The insidious thing with this virus threat is that until they have antibody testing or more easily available COVID testing, you go back and forth from feeling like you are fine to feeling like these are your last days on earth and you will never hug your kids again.  I am actively avoiding them now.  They are all upstairs while I am hunkered in the basement with a mask on.  Hopefully, I'll feel better in the morning, and it just lack of a good night's sleep.

***

Here's the latest stats.  I continue to monitor the new hospitalizations, which I think is the most accurate predictor of where this headed.  Here's my chart tracking Fairfield County (closest to New York), New Haven County (in between us and Fairfield) and Hartford County to get a gauge on whether this thing is starting to wind down or just winding up to deliver a knockout blow.  I was feeling better yesterday about it's trajectory.  Today coupled with articles about how COVID will continue to "stalk" humans for a long time to come, I am a bit down.

Data comes from DPH daily reports.  There wasn't one I could find for April 6 so I just did the math.  I also don't have ready access to all the reports prior to April 3 that show the ascent.  And here's the total case count, which would be much higher if testing wasn't so hard to come by.

  

Winter is Coming?

 New studies suggest huge undercount of coronavirus infections — but are they right?

I have been holding out hope that many more of us than could be imagined have been exposed to corona and are asymptomatic. And this means that in no time at all we as a country have herd immunity, so that even without a vaccine we can go back to the world as it once was, with sports and travel and friends and no fear of too soon death.

The article suggests that the recent studies showing widespread asymptomatic spread have some statistical errors, and may not be all they are cracked up to be.

Here’s the punch line:

Whatever the true fatality rate, more than 40,000 Americans have died from the coronavirus. California’s new serology tests suggest that many more will die before the pandemic is over.
Until we get both an effective antibody test and we do widespread testing, we won’t know for certain, but the evidence seems to suggest we are still very early in this epidemic.

Later today I read stories with the head of the CDC Director Robert Redfield warning that this winter may be bad.

CDC chief warns second COVID-19 wave may be worse, arriving with flu season

CDC Director Warns Americans Of Potential Second Wave Of Coronavirus This Winter

"There's a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through," he is quoted as telling the Washington Post.

It may be spring now, but already they are talking about winter coming. I’ve heard that line before.

***

In Connecticut, hospitalizations are up again, particuarly in Hartford, and another 92 have died.

Nursing Home Slaughter

 In Connecticut there are two nursing homes side by side, one is the north building, the other is the south building. They are owned and operated by the same company. I’m guessing the buildings are maybe ¼ mile apart. I have transported patients in and out of both buildings over the years.

35 people have died of COVID-19 in the North building, 0 in the South.

A Connecticut nursing home, Kimberly Hall North in Windsor, has had 35 deaths due to coronavirus outbreak

They had the same protocols, and similar staffs.

What happened?

COVID 19 got in the North building and room by room started killing old people.

Like a school-shooting, if COVID had made it in the South building the same thing might have happened.

It shows how deadly and infectious the germ is.

No nursing home is safe once COVID-19 bursts through the door.

PPE Update

The state Health Department sent out updated guidance on COVID-19 for health care professionals.

Here are some of the highlights.

1. Surgical masks should be worn when providing patient contact.
2. A N-95 should be worn when aerosol-generating procedures are being performed.
3. Anyone in a health care facility (patients, visitors, staff) should have at minimum a cloth mask on.
4. Anyone entering health care facility should have temperature and symptom screening
5. Patients with fever and symptoms consistent with COVID-19 should be placed in isolation under contact and droplet precautions
6. Hands should be washed before and after donning and doffing of isolation gowns
7. If you are exposed to COVID without protection, you can continue working as long as you don’t have symptoms, provided you wear a facemask and monitor yourself for fever and symptoms for 14 days.
8. Testing should be reserved only for those with symptoms.
9. Health care workers should limit their work to one facility. (Many at hospitals and in EMS have multiple jobs)
10. Antibody tests are currently unreliable and should not be used to determine who might have had COVID and who might be immune.

Here at our hospital as well as on the ambulance, I get my temperature taken on entry.  At the hospital they had some new camera like device this morning that is supposed to be more accurate.  It clocked me at 94 degrees.  There is also a new sign on the elevator.  Instead of limiting each ride to three people, it is now done to two.  Our cafeteria has started selling toilet paper, milk and bread to employees.

As far as my own PPE, I have made some changes to better protect myself.  When treating a known COVID patient or taking care of a patient who I suspect may have COVID, I now wear a second gown on my 6'8" frame as an apron to provide protection from the waist down so for when I am in the back of the ambulance, the patient's arms are not on my pants when I am doing an IV or administering medication.  I still have gaps at the wrists between the too short gown sleeves and my gloves -- a gap I plan in the future to fix with tape.

***

Meanwhile the latest Washington University model shows an uptick in projected deaths for Connecticut up to 2,884 by August 4 where their previous model predicted 2,732.  The model assumes Connecticut maintains its current social distancing practices through June.  It does not take into account a second wave.

Hospitalizations ticked up again.

And I had my busiest day ever at the hospital notifying EMS of patients they had transported who tested positive for COVID here. 

Antibodies

 

I wish there was an antibody test for COVID-19 that I could take right now and that it would be accurate.  I wish it would show that I already had COVID-19.  I would go “Yes!  I knew it!  I knew I had it!”  And I would feel a great well of relief.

The problem is those tests are not widely available.  And, surprise, many of the tests are completely bogus.

Dozens of coronavirus antibody tests on the market were never vetted by the FDA, leading to accuracy concerns

I have also read that some people who have had COVID-19 don’t produce antibodies.

SARS-CoV-2 Antibodies Undetectable in Some Recovered Patients

 Also, no one knows how long the antibodies last for.  The antibodies for the corona-caused common cold rarely last more than a couple months.

What Scientists Know About Immunity to the Novel Coronavirus

Anyway, I hope I had it.  I hope I have antibodies.  And I hope neither I or anyone in my family, or my friends, or the world, gets it again.

Dreamer.

Antibody tests could be key to reopening the country. Here's how they work.

Update: 4/21  

Here is a new paper published by the Infectious Disease Society of America about Antibody Testing:

Antibody Testing Primer

Key Takeaway:

The current antibody testing landscape is varied and clinically unverified, and these tests should not be used as the sole test for diagnostic decisions. Further, until more evidence about protective immunity is available, serology results should not be used to make staffing decisions or decisions regarding the need for personal protective equipment.

The Worst is Yet Ahead

 As many in the world begin to look to reopening their economies, the World Health Organization Director-General Tedros Adhanom Ghebreyesushief warned today “the worst is yet ahead of us.”

He raised the specter of the Spanish flu, calling COVID-19 a “very dangerous combination ... like the 1918 flu that killed up to 100 million people.”

“We have been warning from Day One,” he said. “This is a devil that everybody should fight.”

WHO chief on coronavirus pandemic: 'The worst is yet ahead'

I mentioned earlier today that I have been reading The Great Influenza: The Story of the Deadliest Pandemic in History by John Barry.

Three chilling facts.

It was the second wave of the Spanish flu that laid waste to the world.

The people it targeted, unlike COVID so far, were the young and healthy, those with the strongest immune systems.  The Spanish flu killed more people between the ages of twenty-five and twenty-nine than it did people over sixty.

It killed with great speed. In some cases a perfectly healthy person would take ill and be dead within hours.

Here's two other comparisons to modern day.

After the first wave passed, some declared the epidemic over and started to return to normal.

The author writes: “The virus had not disappeared. It had only gone underground, like a forest fire left burning in the roots, adapting, honing itself, watching and waiting, waiting to burst into flame."

In Philadelphia, a city run by a Tammany Hall, a system that relied on patronage over professionalism, many top medical people in the health department were replaced by hacks at a time when the best people were desperately needed.

“Most jobs in the Department of Health were not patronage positions, so to create vacancies Tammany began to smear the best municipal health department in the world.” Division chiefs were fired and highly respected physicians removed from their posts.

Politics before science. Sound familiar.

Trump's plans to cut WHO funding amid the coronavirus could exacerbate the crisis and cost more American lives

I started The Great Influenza months ago and found the first part incredibly boring where the writer introduces the reader to the state of medical research at the time and the people who will later play a role in battling the epidemic. Start reading the book instead at Part IV "It Begins."

It has been hard to put down from that point on, but sometimes I have to put it down because it scares the hell out of me.

***
A sad day in Connecticut. Hospitalizations, particularly in Hartford rose, and 204 deaths were added to the death roles that now exceed 1300. The high number represented some catch up numbers from days earlier that hadn’t been reported.

April 20, 2020 COVID Report

 

Nursing Home

 COVID-19 will change many things about America. One may be the care our older Americans get at nursing homes of skilled nursing facilities as they are largely known nowadays.

Much of the war against COVID is being waged in these homes. Here in Connecticut, 40% of all deaths have been nursing home patients. Many of the patients coming into our hospital are coming from the same nursing facilities where others have tested positive. The radio patch comes over: "89-year-old female, short of breath, room air sat is 88%, fever of 103.1. Not tested yet, but many in her facility are COVID positive. Respiratory isolation precautions in effect.”

There is one nursing home in our service area where I work as a paramedic that has a very poor reputation, made worse by their COVID response. We in EMS judge a nursing home on several things, smells, appearance, readiness of the staff to give us a report when we arrive, but most of all on the condition that the patient is found in when we arrive.

Some nursing homes the 911 calls are never very interesting. High blood pressure, altered mental status, abnormal lab values; others are always bad-respiratory distress, sepsis, cardiac arrests.  The first group sends their patients out at the first sign of trouble; the latter group sends them when they are in common parlance, "shitting the bed."

The best way to rate nursing homes, if you could do it this way, would be to count what percentage of the time the ambulance leaves for the hospital lights and sirens after picking up the patient versus going with speed of traffic which is how the majority of EMS 911 trips to the hospital go.

When you show up at a nursing home and you can’t find a staff member and the patient is severely hypotensive or in major respiratory distress and they can’t tell you when they were last seen normal, that is an issue. The other response we often get is, “I don’t know, I’m just an agency nurse. I’ve never seen her before.”

This happens frequently. The worse the nursing home the more it happens. If a home can’t keep its staff, you end up temps and agency nurses. That is not good for patient care.

Today we pick up a woman found on the floor with a severe gash on her forehead. No one knows how she fell. She can’t tell us. The nurse looks at her medical records and tells us the woman has dementia. “How does this compare to her normal?’ we ask. “I don’t know. I’ve never seen her before.” Any other medical history you can tell us about?” She hands us a mimeographed sheet of paper from several weeks ago that is barely readable both due to penmanship and the number of times it has been copied.

Because of the reputation of this facility, as a COVID hot spot, we came in fully gowned with face masks on. The woman’s pulse saturation is fine, she is not feverish, but she is talking gibberish and the lac on her head is deep. We take her to the hospital. On the way I read through the stack paperwork the nurse handed me in a red envelope.

I can barely make out the words COVID. I have to put my glasses on underneath my goggles to make it out but there it is COVID +.

There was no sign on her door, The nurse said nothing about it. I’m glad we had our PPE on.

I know many people labor in these facilities for low pay and they are horribly understaffed, so I am not blaming the workers. I blame the system. We all saw how COVID devastated the first nursing home in Kirkland, Washington when the epidemic was first beginning.

https://www.statnews.com/2020/02/29/new-covid-19-death-raises-concerns-about-virus-spread-in-nursing-homes/

We had to know it was coming. COVID is burning like gasoline in their homes, and even if we turn the corner on this wave of the epidemic, if we have flattened the curve and the numbers drop, does anyone thing we are prepared for the next wave or the next epidemic.

Let’s have an economic come in and look at where the money is going in these homes. The nurse’s aren’t rolling in dough. Many ride the bus to work and have two and three jobs. They leave at first chance for better work. No wonder there are so many pool or agencies nurses in these places or nurse’s who say, today is my first day. The money has to be going somewhere. How much do the administrators make? Who are their bosses? Are these homes run by for profit corporations. Or maybe the problem is the state. Maybe these places are truly underfunded for what they do in our society. Maybe we need a different model. This can’t happen again.

70 Died at a Nursing Home as Body Bags Piled Up. Here's What Went Wrong.

COVID targets nursing homes and prisons. Think about that.

I remember what my old partner Arthur used to say when we came out into the sun after leaving another patient at a nursing home.

“Just put a bullet in my head,” he’d say.

Tonight when I get home, there was a story in the paper about the state boosting Medicaid payments to nursing homes and sending state regulators out to each home to inspect them.

Daily coronavirus updates: Hospital cases in Connecticut continue to decrease slightly; Governors name seven-state council to re-start economy; Lamont increases funding, oversight for nursing homes

Here’s the best part: The state’s increased financial support will be applied toward employee wages, including staff retention bonuses, overtime and shift incentives, new costs related to screening visitors, personal protective equipment for staff and cleaning supplies.

Bravo.

SeeSaw

 The see-saw emotions of this epidemic are unrelenting.  The data is looking better.  While Hartford continues to increase its hospitalizations, the numbers are slowing and both statewide and downstate, the numbers are going down.  While there were another 41 deaths, this number is also starting to slow and be less that what was once feared.  With more talk every day of reopening the economy, you can start to envision a more normal world, then I started reading this book:

I'll have more to say on it in a post tonight, but the hit home message was, pandemics come in waves.  Let's hope our second wave is not like the second wave that struck the world in 1918.

 

Tiger

 

It’s 12:59 A.M. I have given up on sleep. Fortunately tomorrow is my one day off (I will still go into the office to make my COVID EMS notifications) but I will go in at whatever time I feel like and will only stay for a couple hours. It’s not like I have to get up at 4:30 to dress in the darkness for a 12-hour shift on the ambulance.

I am up not because I can’t sleep, but because my sleep is restless and tormented, and because of the tiger.

When I last reported on my nightmares. I was being terrorized by the corona germ that looked like Spongebob. He and I faced off on a basketball court without hoops and I was considerably larger than him and I had a blanket that I tried to smother him with, and even though he escaped, and continued to come at me, making a strange high pitched shrieking sound, I could easily kick him off before he caused me damage. He had no teeth or nails. He was after all only made of sponge,

Now it is a Corona tiger that comes at me. I am no longer on a hoopless court, but in a small two story house. At first the tiger came in the open front door from the yard. But now he comes out of a large square hole in the floor from his basement lair.  I have a host of weapons against him. Giant pillows I can throw at him. Furniture I can pile high that he will have to jump over and doors that I can escape behind. We have a game. He tries to get me and I try to get away, occasionally whacking him with a pillow or a wood board with nails on it. But each time we play, he gets bigger, and my weapons of defense get flimsier. I start on the second floor now and throw stuff on him from the balcony, and he comes up the stairs after me, and I leap over the furniture I have piled high against him, and I escape into the closet with the flimsy wooden door that does not lock. The last time I felt the heat of his breath as he roared outside the door, and I was saved only because he grew bored and wandered elsewhere in the house, and I awoke, but I don't want to play again. He is full size now. When he stands on his hind legs, he can reach the second floor with his sharp clawed paws. I know the next time he will leave deep scratches on me that will not heal.

I don’t want to play anymore. But he will not leave my house. I can hear him pacing downstairs.

The pandemic is giving people vivid, unusual dreams: Here's why.

R0 Number

 We are reaching our COVID-19 death peak in three days in Connecticut according to a new model by the University of Washington.

Connecticut model

Already people are discussing how we will reopen the state. Our Governor is a decent, cautious man and he wants to make certain he doesn’t open it too soon to let a second wave attack us.

Meet the team advising Gov. Ned Lamont on how to reopen the state after coronavirus infections subside

To understand this pandemic and the reason for social distancing, you must understand the virus’s RO, or reproductive value. The RO represents the number of people someone with the virus will likely infect. If the RO of a virus is 2, each person who gets the disease is expected to transmit it to two others, and those two spread it on to another four, who spread it on to eight, and the number continues to grow exponentially.

The higher the RO number, the more likely the virus is too spread. No one really knows what the RO is of COVID-19, but the World Health organization has estimated it to be between 2 and 2.5

To stop an epidemic, you have to get the RO down to less than one. Social distances, face masks, PPE, all of these things help lower the RO. If you get the RO down to 0.9, the diseas will begin to die off.

But, let's say you get it to 0.9, and then you loosen up the restrictions, it starts roaring back.   1.2 is far worse than 1.1. Even a single 0.1 increase can be the difference in many lives lost and whether or not a health care system gets overwhelmed.

Here is a great video of German Prime Minister Angel Merkel explaining it.

https://youtu.be/22SQVZ4CeXA

In her words, the situation is “thin ice...where caution is the order of the day, not overconfidence.”

The two best way to keep a virus RO below 1 is through herd immunity. That comes either through immunization or through enough people having already been infected that the virus runs out of new people to infect. When you lack herd immunity, all you have left is social distancing.

I hadn’t thought of this before when I desired for the state to be reopened, and in particular, for the swimming pool across the street to open and the schools for my children.

Until we have widespread testing that reveals whether of not we have herd immunity (I believe we are far from it), and or a vaccine (1-2 years away), corona is going to be among us. And while at times it may seem like we have flattened the curve, it can easily come raging back.

Here’s my scary article of the day:

Epidemiologist Delivers Blunt Reality Check On Current Phase Of Coronavirus Pandemic

No Matter How Much You crunch the Numbers This Epidemic is Just Getting Started

Rest Day

 For the first time, net hospitalizations fell in Connecticut.  Still 1,938 people remain hospitalized.  Another 50 died.

As I've mentioned I follow the patients EMS has brought into our hospital who test positive so I can alert EMS for them to check if they had any exposures.  For the most part now, it seems they are all using their PPE even for cases that may not jump out as COVID.  The most telling barometer of a COVID positive test seems to me is the low oxygen pulse saturation, even more so than fever.  There are also an increasing number of patients being brought in who have already tested positive for COVID, but their breathing has gotten worse to the point they need to come in.

Just about all the patients being hospitalized are old and with comorbidities. Many from nursing homes. I read a note where the doctor mentioned talking to a patient and telling her that due to medical history, if she were to worsen her prognosis would not be good.  She made plans to apply for the no visitor exemption in case that were to happen so that her family could say goodbye. 

The paper says 40% of the corona deaths in Connecticut are nursing home patients.  I am not surprised.  Most of our EMS COVID positive patients are from nursing homes.  The paper had a list of all the nursing homes in the state and the number of cases and fatalities at each.  I was surprised to see how many died in some homes across the state.

Nursing home deaths now make up 40 percent of fatalities from coronavirus in Connecticut as pandemic spreads

Other than a few hours in the office, today was my day off and since it snowed last night and was cold, I spent a good portion of it napping, and then later worked some on cleaning our garage, which is a terrible mess.  I took several loads of clothes to drop in one of those shopping center clothing bins as well as throwing out a bunch of junk into our garbage pails.  I tell my wife if Corona gets us, we need to leave a clean house.  She promised to spend tomorrow in the garage.  We'll see if that happens.  There over a decade's work of junk in there.

She is upstairs on the couch now watching "The Wedding Crashers" and her laughter fills the house.

My middle daughter is sulking in her room because her mother forbid her to visit her boyfriend's house out of Corona fears.  (I would have let her go).

The youngest, not feeling well today, is sleeping on the other living room couch.

I need to be sure to take my melatonin tonight and hope I have a peaceful rest and the tiger does not return.

I work 12 hours on the ambulance in the city tomorrow.

 

A Different Day

 I worked twelve hours in the city today.  My partner and I lucked out as far as the COVID calls went.  I heard a ton of them go out, including a couple of cardiac arrests that sounded like they fit the bill of a person not feeling well for a couple of days with a fever, arresting at home.  There were also an increasing number of COVID patients being discharged and taken to special COVID capable nursing homes.  Crews still have to wear their full PPE on these calls.  We did eight calls, and maybe there was a stealth COVID in the bunch -- and we now not only wear masks on all our calls, we mask all of our patients-- but nothing that stood out like the calls I was doing last week.  I had two people with pretty severe dehydration who answered no to all the COVID questions, and had decent pulse saturations in the 90s.  My partner and I had a number of EDP-emotionally disturbed person calls--and for the first time in a long awhile-- a what we call "lawyeritis" call where the patient was clearly not injured but was looking to sue a store where she allegedly slipped and fell.  Normally we do a lot of these -- people in minor motor vehicle accidents, holding their necks and backs and moaning in whispers.  Lately, people can get pretty smashed up and still not want to go to the hospital out of Corona Fear, but maybe that is changing.  We did one heroin overdose who came around with stimulation and we spend over a hour by the river watching the fire department boat look for a man who jumped up the Founder's bridge.  He wasn't found, and my guess with the way the Connecticut River was flowing, he may have been carried all the way to Long Island Sound.  Once the operation went from rescue stage to recovery stage, we were dismissed.

Each day I have worked I have noticed new changes and safeguards being added.  Today our company had one of our employees at the hospital talking to all the crews, discussing the proper way to take off PPE and how best to disinfect out supplies.  At then at the end of the day, they have another employee who disinfects all the equipment we bring in from the heart monitor to the portable radios and even the keys to the narcotics box. One of the hospitals opened up an outdoor triage tent where the hospital registrars and the triage nurses were on the other side of clear plastic from us, which made it hard for me to hear being half deaf from 30 years of sirens and having to hear a soft spoken nurse through her N95 and then through the plastic and then competing with the howling spring wind.

After a big rise in the numbers yesterday, today saw statewide hospitalizations with their smallest net gain in the last two weeks. The newspaper (for me it is now an app on my phone) had an article about Connecticut beginning to plan for reopening the state.  It said we are still a long way off, but at least they are talking about how to do it.

An unprecedented plan to re-open Connecticut after coronavirus could include surveillance, confinement and extensive testing, but it raises questions about privacy rights

I am home now and hopefully will have a better night sleep than I did last night when my thoughts would not be still.

Peace to all.

Way to Go

 

He was found unresponsive on the city bench with a needle in his hand. The first responding police office shook him and he was able to come around with naloxone.  By the time I arrive, he is alert and angry. Three police officers stand around him with their arms crossed. He doesn’t want to go to the hospital, which is okay with them, as long as it is okay with me. They want me to check him out.

He is, I’m guessing in his late twenties, a lean likely once handsome man in an army jacket. His face is now pockmarked and scabbed, as are his arms. “Leave me the fuck alone!” he says. “I’m not going anywhere. I’ve got rights and I fought for them!”

“I just need to ask you three questions,” I say, holding my arms out in a peace offering. “I have to ask them of everyone. What day is to day?”

“Thursday,” he says, refusing to look at me.

“Where are you right?”

“Main Street.”

“Who’s President?”

“The fuckhead, just like all of you are fuckheads.”

“Okay,” I say. “Just a couple more questions if I can.   Do you know where to get help if you need it?

“Yes.”

“You know where to get clean needles?

“Yes, I just came from there.”

“You know where to get naloxone?”

“Yes. “

“You know you can started on suboxone in the ED.”

“I don’t want to get on suboxone. I don’t want to stop using. My girlfriend, that crack bitch, just cashed her stimulus check and we got a motel and we were bingeing and then she took the fuck off on me. You think I trust anybody? You think anyone gives a shit about me. Fuck all of you!”

“Just trying to help.”

“I don’t need any help. I went to both hospitals and nobody can help. I've got bad sores.  I can’t even walk on my legs they’re so fucked up. No one can help. Leave me the fuck alone.”

“We’re happy to take you to the hospital, if you want to go. You can get you something to eat, maybe they can help find you a bed.  At the least they get you something for your abscesses.”

“No, fuck all that.”

“It’s available to you, if you want us to help.”

“There’s no help for me. Nobody gives a shit about me.”

“We all do.” The officers nod in agreement.  We are earnest about wanting to help, but right now he is not taking anything in. His anger is too strong.

“You think I’m a scumbag,” he struggles to get to his feet. “You all think I’m a scumbag. Look at this.” He takes out his cellphone and furiously hits away at the screen. “There look at this. This is me.” He holds it out defiantly for us to see."  It is a young man in full military uniform in front of an American flag. “I’m no piece of shit. So fuck all of you!”

He turns from us then, and starts walking down the street with an awkward painful gait. He gives us the finger and then turns away for good.

From under the bench I pick up the syringe and a torn heroin bag that has a number one on it and the words in blue “Way to Go.”

 

 

Latest Model

 On the day the Connecticut death toll topped 1,000, the University of Washington has revised their model for Connecticut down from 4,0003 expected deaths by June 3 to 2,732 deaths by August 4.  They now project the peak to be on April 21 one day earlier than the last model.

Connecticut Model

Hospitalizations only went up 20 in Connecticut with the first ever decrease in Hartford County.

At the hospital I work at a previously health young man, who spend weeks on a vent was wheeled out of the hospital to the applause of many of cared for him.  He was one of the first to be admitted and when I saw his name was no longer on the list of the in patients, I was initially afraid he was one of several who had died, but was thrilled to see he had fought his way through.

 

Turn for the Worst

 Not the best news today.

First off, I learned a friend of mine has been admitted to the hospital after taking a turn for the worst at home.  My friend is not on a vent, but requires 100% 02 by nonrebreather mask.

It is a reminder that behind each of these case numbers there is a face, a soul, a friend, a fathefr/mother or son/daughter, a person knocked low by this modern plague.  If there is a reason to recommit to social distancing, it is the knowledge that someone you know is ill, and other people you know could suffer the same fate we if are not all careful.

Hospitalizations went up in all three major counties.  It is particularly troubling because F airfield, the county closest to New York shot back up.  What we want to see here is the numbers start to dip below the 0 line, so we are decreasing the number of people in the hospital, although that will probably lag the true turn because most people are in the hospital for at least two weeks.  I've mentioned before my office is right by the ambulance entrance, and while the numbers of people being brought in on stretchers continues to go up (for the second day in a row, I had my highest number of EMS notifications to make), for the first time, I am starting to see EMS in full PPE wheeling masked patients past my office the other way, heading out to their ambulances to bring the patient likely to a COVID skilled nursing facility instead of into the ED. 

I am hoping to report today on the updated Washington model (due out today), which last predicted 5,426 deaths by August 4, 2020 with a peak of 168 on April 26, 2020.  

As a note:  My charts come from data released by the public health department every afternoon.  here's today's report.

COVID Update CT April 15, 2020

 

Hypoxia

 Pouring rain and violent wind today in Connecticut.  It almost blew our hospital tent off the mountain.  

I am home now and just finishing up making notifications to EMS services about COVID-positive patients.  Curiously, for the first time, one of the notifications was for a patient I was involved with as a paramedic.  Normally when I work in Hartford, I bring the patients to the two large Hartford Hospitals.  This patient came from a suburban town and wanted to come to the hospital where I work when not being a field medic.  The suburban medic who handed the patient off to my partner and me said the patient was negative for the COVID screening questions, but since she was old and her complaint was shortness of breath even if she didn't look short of breath, I rode it in instead of my BLS partner.  I also put on my yellow gown before I got within six feet of the patient.  I believed her chief complaint was CHF weight gain, but she was hypoxic in the high 80s.  That sign alone -- hypoxia by pulse SAT-- I have seen in too many patients that turned up COVID positive.  And sure enough.  They swabbed her and it came back positive.  You can't be too careful.  As an aside, today was the most EMS notifications I have had to make in one day.  Maybe the wave is getting closer.  I still have a bunch of patients I am monitoring for their test results before notifying EMS or deleting them off my list.

It is only 8:30 and I am getting ready to go to bed.  The daily state COVID results haven't come back in yet.  What a sorry thing my life has become.  Rather than rooting for the Celtics and sitting on the edge of my seat for the fourth quarter action, I sit here waiting for the day's COVID results which usually come by email, as early as 4:30 P.M. and rarely this late.

I am down in the basement again because I got in an argument with my wife.  I accidentally coughed on her.  It just sort of burped out of me before I could cover it.  We already made up after our brief fight.  I guess I am still a little wired.  I used to swim every night and that always relaxed me at night so nothing would bother me.  I'd come out of the pool building and breathe the night air deep into my lungs.  Life was good. 

I am worried I am getting out of shape.  If I was younger, I would be in the mood for a couple of drinks, but they don't seem to do it for me anymore.  They disturb my sleep and make me feel blah the next day.  I just want to go to bed so I can wake up and tomorrow will be today, and hopefully it will be a better one than this one.

On the lighter side:

Nudists told to wear face masks by police

Just checked again.

Damn.  Still no results.

***

Next morning.  Finally got the update.  Everything up.

Fatal ODs

  

The Connecticut Department of Public Health just released a warning to local public health directors of increased fatalities due to opioid overdoses, based on recent data from the Connecticut Medical Examiner's Office.

This has been a feared response of public health authorities in the midst of the COVID-109 epidemic. Historical data showed increased substance use in the aftermath of Hurricane Katrina and 911. Depression and post-traumatic stress increased markedly as well as substance us, and while the rates of PTSD and depression eventually dropped, the rates of substance abuse stayed high.1

There are many reasons why substance abuse may increase and be more dangerous during the COVID-19 crisis.

Established drug supply lines are expected to experience disruptions that may force users to buy from unfamiliar sources, increasing their chances of overdosing.

Training and substance outreach programs are either closed or have limited hours.  Some have moved on-line, which is okay if you have a home and a computer. Not so much if you are displaced.

People may not have access to the help they need as well as reduced access to naloxone and clean needles.

Isolating people with existing mental health issues may lead former users (with now lowered tolerance) to return to substance use.

The increased release of prisoners with history of drug use puts them at risk for overdose due to their lack of tolerance.

Patients with undiagnosed COVID-19 may be less resilient if they do overdose due to reduced respiratory capacity.

And people without work, with increased economic and social pressures, may seek escape.

***

Last Friday, I responded for a report of an unconscious person. I arrived first and was let in the apartment building by the superintendent. I find whenever I am sent for a similarly dispatched call and the superintendent meets me at the door and leads him up the stairs and down the hall at an unhurried pace, the result is usually always the same.

The apartment is vacant. No furniture, no boxes, nothing. Freshly painted walls, floors neatly swept.

“In there,” he says, pointing to the room at the end of the hall.

There is a single mattress in the room. A woman with her head on a backpack and a ragged blanket over her is clearly dead. Her head is purple. She is cold to touch with rigor mortis and dependent lividity. After running my six second strip of flat line and calling the time, I look for signs of drug paraphernalia, but I can find nothing. There is a single cup with eight or nine cigarettes smoked to their hubs. No needles, no works, no heroin bags. Nothing to suggest this is a drug overdose. I am guessing she is in her fifties. The police arrive and I hand them the death information, then grab my gear and leave.

On the radio I hear a medic unit that was dispatched for a person unresponsive in a port-o-potty in a park across town clear with a presumption. That port-o-potty is notorious for drug overdoses because it is so close to heart of the drug-dealing on Park Street. I regularly check there for heroin wrappers to see what the latest brands are.

A couple hours later I am driving down Albany Avenue when I see Mark Jenkins sitting on the back of his outreach truck, out in front of his walk-in center which is closed. The center’s hours have been reduced during the outbreak, but he still gets out as much as he can in the van, which has flags on now to make it more recognizable. I pull a U-turn and park in front. He tells me they are upset because they have lost another member of their family. By family he is speaking of the community he serves, the men and women who come by the center or he and his outreach workers talk to on the streets or in their homes, be they apartments, vacant buildings or homeless encampments.

“Are you talking about the guy in the port-o-potty?"

“No,” he says, clearly not following me. He mentions the address where I found the dead woman.

"I was there," I said. "I didn't recognize it as an OD."

Someone must have cleaned the scene, he says. He tells me she was a regular user. They saw her every day at the center. He mentions her by name. I wonder if I have met her. I stop by the center often, but the face of a dead woman and the face of one with a living soul are not the same.

Mark tells me he is worried. Now in this time of COVID we are telling people to isolate, to distance themselves, which is opposed to everything we have told the substance use community in the past. Come together, look out for each other, there is safety in groups.

The battle is all around us.

We are in this together.

Be well.

 

1 NIDA. (2005, August 1). Bulletin Board. Retrieved from https://archives.drugabuse.gov/news-events/nida-notes/2005/08/bulletin-board on 2020, April 14

 

Aliens

 A busy day in the city yesterday. I was in the fly car, which means I listen to the fire radio and dispatch myself to priority one calls. Because the fire department get the calls before our ambulance dispatchers do, a self-dispatched fly car medic helps considerably with the response times. Since I am already in my vehicle, I am often the first one to arrive. If I get there and the call turns out to be an accident with no injuries or a presumption/dead body, I can call off the ambulance. If it the ambulance gets there, but it turns into a refusal, I can take the refusal and get the ambulance back in service. If a crew needs a lift assist for a bariatric patient, I go help. If a BLS crew needs a medic, I can intercept with them, rather them having to wait for an ambulance with a medic to respond.

In the afternoon, I was sent out to suburb along with a BLS ambulance priority one for an unresponsive patient in a skilled nursing facility (SNF). I got there first and grabbed my monitor, house bag and new blue shopping bag filled with PPE. I entered the building wearing just my goggles, surgical mask, and gloves which I try to always wear. The staff directed me down a hall and through a set of double doors. Suddenly, it was like I was on a different planet. The hall was bright white, the people working there all wore what looked like space suits, Tyvek Protection suits with face shields.

Some of the aliens appeared to be nurses working feverishly at their med carts, while others appeared to be maintenance men, all holding spray bottles of bleach in one hand and a variety of scrubbing equipment in their other. Meanwhile I walked down the hall like a wild animal in the middle of a shopping mall, all of the aliens stopping to watch me pass like what strange naked creature was I. I had to go through a second set of double doors and the next hall wall was more of the same. When I came to the patient’s room, I set my isolation bag on and proceeded to try to put my yellow napkin gown PPE, which in order to fit on, I have to take off my jacket. I also needed the help of an EMT, who was there to pick up a patient in another room, to tie my gown in the back.

The nurse in full body alien suit just shook her head looking at me. My napkin gown doesn’t extend halfway to my knees. When the call is over I am supposed to put my gown in a biohazard bag. But what about the rest of me from mid femur down? Fortunately, the patient was no longer unresponsive, but she was still pale and diaphoretic and delusional and likely COVID positive. Her tongue was as dry as the desert so I gave her some fluid in the ambulance, her arm resting on my leg, which I tried to set my gown up on. At the hospital we went through the decon room, and moved to a hospital stretcher, where the nursing staff brought her to an isolation room. I doffed my gown and PPE, washed my hands and then went to write my run form. When this all started, we weren’t even wearing masks unless people had been to China. Now others are wearing space suits and the government has just relaxed the exposure rules to keep us working, to keep our ranks from being depleted.

CDC Issues New Return-to-Work Guidelines

Implementing Safety Practices for Critical Infrastructure Workers Who May Have Had Exposure to a Person with Suspected or Confirmed COVID-19

I sure hope I have already had corona and it was either when I was sick in late Jan/early February, or I had an asymptomatic or mild case that presented like what a 61 year old normally feels like, because I don’t see how I can avoid getting it. I just don’t want to wake up with a raging fever, short of breath, and find myself six days later on a hospital vent with not much more than a 50% chance of survival according to the latest data. The PPE we have is inadequate, and we largely have to rely on ourselves, each other, our partners, other crew members and facility staff to keep everything in our environments as clean and germ free as possible.