Overdose Awareness Day

 800,000 Americans dead since 2000. No end in sight.

People are dying because they use alone and their drug supply is contaminated. In the age of fentanyl, every bag or counterfeit pill bought on the street could contain a lethal dose.

Stopping fentanyl at the border isn’t going to work.

The War on Drugs (Interdiction and Prohibition) has been a failure. Community naloxone only goes so far. To significantly decrease the deaths, we need safe injection sites, decriminalization and creation of a legal safe drug supply.

Conditions of Employment

 Many years ago, a paramedic I know who worked for another company got into a spat with a nurse at a dialysis center.  I don’t know the details of the spat.  It sounded like nothing more than two people in a bad mood snapping at each other.  Nothing that occurred resulted in a suspension or discipline for the medic or the nurse.  The paramedic, however, based upon the nurse’s complaint to her supervisor, was barred from the dialysis center by the center.  The center told the ambulance company he cannot enter our premises. To my knowledge he had no hearing, no chance to present a case.  He was simply banned by a private business from entering their facility.  What did this lead to?  His apparently apologetic bosses had to fired him from his job.  Not for poor performance or for anything he did or said that day. he was fired simply because as a condition of his job, he would at some point in the future, be required to enter that center either on a transfer or an emergency call, and his banishment from that center was a problem.

Again, I don’t know all the details, so we can call this a hypothetical case as opposed to a real case.  Real or hypothetical, I thought it was incredibly unfair to the medic, who eventually left the state to work elsewhere.  His employment was subject to the complaint of someone who might simply have not liked him.  Maybe he could have hired a lawyer and battled it, but few in EMS have the money or stomach for that kind of fight.  Some might just say, they are already on the verge of saying I have had enough, this just tips them over the edge.  I’m out of here.

The relevance of the story to today is this —  private facilities are now beginning to mandate that only people who are vaccinated are able to enter their doors.  Not just their staffs have to be vaccinated, but people entering their building to deliver or pick up patients must also be vaccinated.  Some EMS agencies are also mandating their staffs be vaccinated.

I am actually for this.  I see a difference between the two cases.  In the first, the medic, at least in my opinion, is not a threat to the people he will be caring for in the dialysis center. A vaccinated provider, according to the best information I have read, while capable of passing COVID to someone else, is much less likely to do so than someone who is unvaccinated. If my mother were in a skilled nursing facility, I would want not only the staff caring for her, but also the EMTs and paramedics who may have to transfer her in the small contained unit of an ambulance, to be vaccinated.

In our area, the hospital I work for has mandated staff be vaccinated.  The ambulance service I work for hasn’t done this yet, but they have requested everyone’s vaccination status.  I have also heard that a venue that we service will be requiring those who work there, including our paramedics and EMTs, to be vaccinated.  I don’t know if this will include those sent in an ambulance for a 911 call, but it will certainly include those paramedics and EMTs doing standbys.

It’s a crazy world.  I find it hard sometimes to talk with others, and not feel frustration with their arguments.  I have sympathy for the way they feel, but I am amazed at how each individual casts such different weight on the information that is out there. It is as if there are two different sets of facts.  Certainly the politics of recent years has had some effect on this.  I know some have speculated that if Republicans were hardline pro-vaccine and Democrats were saying vaccines should be a choice for individual liberty, many would hold opposite views to what they hold today with the same vehemence.

Recently I was reading an old post I wrote about vaccines in 2009, called Flu Shot, that attests to the fact that vaccine mandates have always been controversial.

For me, in the choice between public health and individual liberty, I land on the public health side.  I believe it is the right for private businesses to make that choice themselves.  I would agree that governments should be able to make that choice too, but it should always come after careful, thoughtful review of the best available scientific evidence, and include necessary oversight.

Our government limits many things we do in the interests of the greater good. We wear seatbelts, we pay taxes, we can’t smoke in certain places, there are restrictions on pollution, etc., certain drugs are illegal.  I may take issue with some of those when the potential harm done is only to the individual.  I give the government more latitude when it prevents the harm being done to others.

I hope as a country, nation and a people that we can survive not only the brutality of COVID, but the deep divisions COVID and recent political battles have laid bare.

Peace to all.

Apparition

Tim was working for the company when I started.  As tall as me and twice as broad, he was a strong EMT — a good lifter, quiet sense of humor, hard worker, gentle with patients.  And if he was standing behind you, no one would think of causing trouble.  One night fifteen years ago, he came in off-duty and turned his uniforms in.  Laid them on the supervisor’s desk.  Said he’d had enough.  He left without another word.  That was the last I saw of him.

Coming into work on Friday, walking into the cavernous ambulance garage that looks the same as it has for the last twenty-five years (except for different people checking out the ambulances or changing oxygen tanks) I didn’t need to close my eyes to see him.  He was still there, walking with a limp from all the back pain, all the patients carried in the days when we did two man dead-lifts, walking away from the life that night, walking out into the darkness.

“What are you looking at?” an EMT friend said to me when she saw me standing there.

 “Just thinking about the past,” I said.

Tim passed away on August 4 at age 64.

Street Lessons

  In 2012, I wrote a series called Street Lessons, but I could just as well call it any of the following:

Things They Didn’t Teach Me in Paramedic School

Things They Might have Taught Me in Paramedic School, but I Was on a Bathroom Break.

Oh Shit!

Things I Learned The Hard Way

Trial and Error

Eureka! or Light Bulb Moments

***

Street Lesson # 1

Don’t Carry Hypotensive Patients in a Stair Chair

Over the years, I have had five patients go into cardiac arrest while I carried them in a stair chair. What does that tell me? It could mean that I carry a lot of patients in stair chairs. It could mean there are not very many elevators in the city I work in. It could mean I have done a ton of calls in my twenty plus years in the field. All would be true. And I can say I have never had an ambulatory patient go into cardiac arrest on me — at least not while I have been ambulating them. My first words to my partner on arriving at patient bedside are usually, “Get the stair chair.” The old saying “ABCs – Ambulate Before Carry” – it is not in my book of sayings.

Still five patients coding on the stair chair seems like a lot — certainly enough for me to wonder whether their coding was in any way related to their being on the stair chair.

So why might they code on a stair chair?

They are sick and dying and called 911, and if we hadn’t arrived as soon as we did, they would have gone into cardiac arrest at that precise moment anyway.

They are sick and dying and the fact that they were being carried down steep creaky stairs scared the last bit of life out of them.

Or maybe they were hypotensive and when we sat them up, their weak hearts couldn’t compensate, and that little extra bit of stress was enough to push them into the void.

I cannot remember the details of all five cases. But I can remember each of them dropping their head back or dropping it forward in a manner that indicated they no longer had muscle control. Sometimes they took a last gasp or two, sometimes not. I am a big believer in working a cardiac arrest right where they code, not losing a precious second in poor or absent CPR. Still it is hard to just stop carrying someone mid-stair case and start rescusitation.

“You know what just happened?” I will say to my partner.

“What?

“The patient just coded.”

So what is the lesson in all of this (Besides, expect if you do enough calls and carry enough people some will code on the stair chair)?

My lesson is — if the patient is hypotensive while supine or borderline hypotensive and they are sick, consider carrying them in a scoop stretcher.

A 20-year-old with a pressure of 80 due to vomiting may be less at risk that an 80-year-old cancer patient with altered mental status, tachycardia and a pressure of 100. If a patient gets dizzy sitting up, then don’t use the stair chair. It may not spare you having them arrest on you during extrication, but it will be less likely to cause harm.

Street Lessons #2 Troubleshooting the Monitor

In paramedic school, you are taught to apply your cardiac monitor to patients having chest pain as well as a variety of other aliments.  Simple enough.  If your teacher hasn’t told you, then your preceptor should be grilling it into you to always bring your monitor in to each call, as well as your house bag.  Some might say you should also be bringing in your suction –anything you might need.  You never know what you are walking into.  But in this post we are going to just talk about the cardiac monitor, and we are going to assume you have it with you.  (At least in cases A-D). Here’s where the problems begin.

Problem A 

Both batteries are dead.  You checked them this morning and you swear they both had four bars.  Now the monitor is either completely dead or the batteries are both down to one and flashing that they need to be changed, and then they go dead.  What happened?  Well, you thought you turned the monitor off after you checked it at the start of your shift, but you didn’t, and all this time the machine has been sucking the batteries down.  I can tell you I have on several occasions been driving to a cardiac arrest and just before I arrived, heard a sudden beeping from the back and the voice saying “Change monitor batteries.”  What do you do?  If you are still in the truck when the battery is beeping, you change the batteries out.  Simple enough.  But let’s say they are both dead and you don’t notice until you are in the house.  You take the spare battery out of the back.  How do you know you have a spare battery?  Because this has happened to you before, so you always keep a spare battery in the back now.  Always.

Problem B

The batteries are good, but when you attach the electrodes, nothing reads on the screen.  You recheck the leads and connection to the monitor, which you unplug and then replug several times, all with no change.  Still nothing.  You take the electrodes off and apply some new ones from the same open bag, and still nothing.  You blame the monitor.  Is it the monitor?  No, some of you may have guessed from your experience or from what I have written that reveals the clue.  The problem is the electrodes are from an open bag and they are dried out.  You were smart enough to switch electrodes, but you took the new ones out of the same open bag.  Try to always get your electrodes from a fresh pack, or at least keep a spare fresh pack in case you have this problem.  I know some medics like to preattach their electrodes, which is okay if you are very busy, but know this — from the moment you take them out of the bag, they start to dry out, and the drier they are, the worse the ECG quality will be until you get nothing at all.

Problem C

You need to do a 12-Lead.  Whoops, you have the regular cable, but the 12-lead attachment cable is missing.  It fell out and no one noticed or you forgot to check carefully this morning.  Either way, all you have is the four leads and your patient is having crushing pain and is cool, clammy and diaphoretic.  What do you do?  A modified 9-Lead.  This is how we did 12-leads before we had Life-Pack 12s.  Take the left leg lead — the red lead, and move it to the V1 position.  Run Lead III in diagnostic mode.  Repeat with V2, V3, V4, V5 and V6.  Label each lead as follows:  McL (modified chest Lead)1, McL2, McL3, etc…  While not exact replicas, they do passably well.  You do this and see hyperacute T waves in McL3 and McL4 and McL5.  Call in a STEMI Alert.

Problem D

This time you have your 12-Lead cables, but that is all you have.  You don’t have the four lead cables and without those, you can’t attach the 12-Lead cables.  Your patient is alert, but very clammy and you can’t feel a pulse.  What do you do?  Take out the defib pads, and apply them to the chest.  Hit paddles on the monitor and while you won’t be able to get a 12-lead, at least you know the rythmn and if it happens to be VT, you are all set.  If if is an SVT, and you want to give adenosine, go ahead, just be certain to hit print.  If it is a sinus, well at least you know that.

Problem E

Okay, so this time you are dispatched to a chest pain call and when you go to grab your monitor, there is no monitor.  D’oh!  What happened?  Who knows, but we could assume what happened to you is what happened to me as chronicled in the post D’oh!  I was lucky enough that my call was not a chest pain, but a BLS call.  Had it been a chest pain, I would have had no choice but to fall back on my BLS skills and call for a paramedic intercept.  Even if I was revealing my lapse and subjecting myself to punishment, you can’t let the patient be harmed.  Go ahead and call for a medic, and hope that your company and or medical control is lenient with you.

 Street Lessons #3  Know Thy Patient

Ahh, the simplest things.  You need the patient’s name, date of birth,  and social security number if possible.  The name is most important.  If the name is John Smith or Juan Martinez, the date of birth helps.

I was a brand new spanking EMT and we had a patient in classic CHF — I am talking hypertensive through the roof, bulging jugular veins, filling emesis basins with pinky frothy sputum.  We had him on a nonrebreather, on a stair chair, out to the ambulance, and lights and sirens half way to the hospital before we realized we didn’t who he was, and he was still working at breathing too hard to get a syllable out.  No name, no DOB, no social, just the address we picked him up at.  Chalk that one up to two excited rookies.

On most calls, if you leave the house without the patient’s name, this is no problem, the patient can tell you.  In the past, I didn’t often bother with this information if the patient was talking to me.  I figured I could get it out in the ambulance.  I look at the elderly patient and say  “You know your date of birth and social security number?”   The patient looks me right in the eye and says “yes, sir.”  Very good.

On the way to the hospital, after I have done an IV and 12-lead, I ask the patient for his date of birth.  “Yes, sir!”  he says.  Same answer to social security number.  I ask him his name.  “Yes, sir!”

Always get the name and social.

I am in the nursing home and the nurse hands me the envelope.  I take a quick look at it to see if there is a name, date of birth and social security number filled in on the paperwork and that I can read it.  Check.  Check.  The patient is unresponsive.  Out in the ambulance, I am checking the patient’s meds to see if they provide a clue to their condition.  I notice then that patient’s name is Mary Wilson.  The problem is the patient is a man.  I send the paperwork back into the SNF with my partner who comes out with an apology and the paperwork for Richard Johnson.

Here’s one.  Nursing home patient is unresponsive.  Ambulance crew takes patient and paperwork.  Patient’s blood sugar turns out to be 29, but he is not a diabetic.  They give him D50, and he comes around, but is still somewhat confused.  At the hospital they keep him overnight to do tests and figure out why he dumped his sugar considering he is not a diabetic.  Plus he is still confused.  He won’t answer to his name.  Later that night, the hospital gets a call from the nursing home to check on the patient.  Who?  The hospital says, we have no one by that name here.  Later the hospital calls the nursing home back.  We do have someone here from your facility named Edward Thomas.  Ahh, no you don’t.  Edward is right here next to me in his wheelchair.  Whoops.  No wonder the man in the hospital bed won’t answer to his name.  Turns out the patient is a diabetic after all.

You have to check the name.  If the patient can’t confirm it, check for a name bracelet.  No bracelet?  Get a nurse to verify the patient and paperwork are one and the same.

You’d think it would be easy, but it’s not.  The times I’ve been on calls and had a first responder hand me a piece of paper with the patient’s name and information on it, and its been the first responder’s previous patient, and not this current one.  The times it has been the right patient and I have put the paper in my right pocket, but then pulled a piece of paper out of my left pocket and started typing in the name on the left pocket piece of paper.  Not the  patient in front of me.

I try hard now.  I introduce myself to the patient and get the patient’s name or get someone to tell me the patient’s name.  Mistaken identity can lead to serious errors, and those we always want to avoid.

Street Lessons #4 Carry Your Gear

Always carry your gear into calls.  I know it can be a pain to do, but nothing is worse than suddenly needing your equipment and not having it.

A woman calls 911 and says “my baby is sick!”  You get dispatched for a sick baby.   You think if it is a sick baby, what do you need equipment for?  Most likely the baby is not really sick, but if the baby is really sick then you can, as my preceptor once said to me, “O.J. it.”  This of course was when O.J. Simpson was known for running and leaping faster than any other human and not known for slashing throats.  “O.J it” meant grab the baby and run for the ambulance.

Many times in my early years as a medic I “OJed” it with sick kids, sometimes doing CPR and tiny breaths as I went, hurtling toward the ambulance, my office where the gear that made me a medic was stowed.  Aside from that clearly not being the ultimate way to resucitate a baby or anyone for that matter, the “sick baby” call doesn’t always turn out to be a sick baby.  The sick baby can be anything from a 300-pound fifty-two-year old son in cardiac arrest to a vomiting parrot.  The 300-pound son you clearly wish you had your gear for.  The vomiting parrot?  Well,  that’s another story.

When I started there was one paramedic who always carried all his equipment in on every call.  Back then we had a black hard suitcase called a biotech for the meds and IV supplies.  We had an intubation kit, we had a large house bag with the oxygen and bandaging supplies, and we had the Life Pack 5 and then the Life Pack 10 monitor.  We also had an orange tackle pedi-box.

Now this medic didn’t bring the pedi-box in on every call unless it sounded like it might be a pedi.  For the sick baby that turned out to be the 300-pound fifty-two-year-old son, he would have had the pedi box there along with everything else where other medics would have had to send their partners running back down to the truck.

He also– and this is what impressed me the most — he always carried the portable battery-operated suction machine in.  Every call.  Me, I only bring it in to a known cardiac arrest, and I can tell you to my embarrassment, two of the last three difficulty breathings I’ve been too have turned out to be cardiac arrests where my preceptee has said, “I need suction!” when he has put the larengyscope in and seen nothing but murky waters.  “I need suction now!”  On its way. but not here yet.

We had a paramedic here who was fired for not bringing equipment in.  She sometimes brought equipment in.  Say it was a known cardiac arrest, she would put a larengyscope, a tube and a 10 cc syringe in her pocket.  I kid you not.  She also downgraded a stabbing because the hole in the chest was “just a little hole.”  Lazy paramedic.  Bad paramedic.

I carry in the house bag and the monitor, and the 02 if the fire department hasn’t gotten there yet, although there have been times when I have climbed up three flights of stairs only to find the fire department also didn’t bring in their 02.  I hate not being prepared.

I carry my controlled substances on me when I go into a call.  While there is some lack of clarity as to what exactly the rules are in our state governing the securing of controlled substances — it ranges from they must always be secured doubled locked in the ambulance unless you have the intention to use them to its okay to secure them on yourself as long as you are on the clock and capable of being dispatched to a call where you might need them.  The issue here is:  what if you respond for a person vomiting and after wheeling your stretcher down many halls and up a couple different banks of elevators in a big insurance company, you find your patient is actually seizing?  You can either 1) Put the patient on your stretcher and wheel them seizing all the way back out to the ambulance.  2)  Give the controlled substances keys to your BLS partner and tell him to get the kit and hurry.  3) Or you can take the controlled substances kit out of your own pocket and stop the seizure now.  I hate being without my gear when I need it.

Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched — the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, “he’s up on the 2nd floor.” We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with gurgling respirations and an ever growing pool of blood around his head. “He got the shit kicked out of him,” the cop says — “steel toed boots.”  “Uh-o,” Steve says to me. “Go get the gear,” I say to Steve.

We work together the next week. No “uh-o” moments we both agree. We’ll bring the gear in on every call. First call of the night is for a “woman drunk wants to go to rehab.” This is a call we do all the time too. We walk in, meet the patient, who says, “I want to go to rehab.” And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door — also up on the second floor. “My daughter is an alcoholic,” he says. “She needs to get cleaned up. I don’t think she’s breathing.” Uh-o. Go get the gear.

I know the gear is heavy, but look at it this way, you are in physical training.  Carrying all that gear up and down stairs will get keep you in shape and keep you young.  Do enough calls, walk up and down enough staircases and you can skip the gym after work and spend the time with your family.

Street Lessons #5 The Hand Drop Test

Anyone new to EMS is likely as amazed as I was at how many patients feign unresponsiveness.  We all likely have had a moment when a more experienced responder has demonstrated the “Hand Drop Test,” where they raise the patient’s hand over their face and release it.  If the hand smacks the face, they pass the test and truly are unresponsive.  If the hand stops or is moved to the side to avoid contact, then the patient fails the test and is a FAKER.  Or so it goes.  The best FAKERS, I was told, know our tricks and so let their hands smack their faces because they are wise to what we were trying to prove.  I was told to look out for these master fakers.*

There is a second more valuable lesson than the Hand Drop Test, a lesson that comes later and often comes painfully to your own performance as a paramedic.  And that lesson is just because a person is aware enough to move their hand to avoid their face, doesn’t mean they can’t also be really sick.

What do you mean?  They have an intracranial bleed?  They failed the hand drop test!

What do you mean?  They are in acute renal failure?  They failed the hand drop test!

I was burned by this early in my career, but never again.

All a person needs to fail the hand drop test is a smidgeon of consciousness, and a quarter ounce of remaining strength.  It merely tests for a smidgeon of consciousness and a quarter ounce of strength.  It does not provide proof that a patient is not sick or injured.

Also, if the results of all your other assessment capabilities still leave you wondering, and you just have to do the hand drop test, make certain that you protect the patient.  A paramedic caused bloody nose should not be considered collateral damage from having to do the hand drop test.

*  I no longer feel it is my job to unmask fakers.  If I suspect someone is faking, I find it easier to just pick them up, put them on the stretcher and take them out to the ambulance, than to try to prove to the surrounding crowd that the patient is conning everyone.

Street Lessons # 6 Don’t Always Believe Your Own Eyes

 When I was a new EMT, I responded to a call for an unconscious person.  In the basement of a house, I found a woman in her thirties unconscious of the floor and her husband shouting frantically that his wife was dying and that he had in fact done CPR on her  for several minutes.  “Help her,” he demanded.  “I am,” I said.  I was kneeling beside her and feeling her pulse, and watching her breathe.  While she was in fact unconscious, her breathing was even and her pulse was steady.  Her skin was warm and dry and she didn’t have a scratch on her.

My partners had told me stories of people doing CPR on living patients and always laughed at them, and while in my career I would encounter this phenomenon again and again, this was first time seeing it, and I thought, I am an EMT, the person is breathing and has a good pulse.  This man is just a layperson who is very panicky and I think it is a good bet she did not actually need CPR when he was pounding on her chest.  Perhaps she is on drugs.  Her husband denied that when I asked.  To this day, I am surprised he did not beat me for suggesting it.  I guess he was clinging to the belief that maybe I could help her.

Well, we got her on the stretcher and out to the ambulance, and wouldn’t you know, ten minutes later, she stopped breathing and we were doing CPR.

A wise person told me once when I arrived on scene to always acknowledge the first responders or the bystander if there were no responders and get a report.  Some reports would be excellent, some would be crazy.  The point the wise man made was to simply show respect.  “I did CPR on her for a couple minutes and then she came around,” the woman would say.  “Great,” I would respond.  And then get on with managing the syncopal victim with the now bruised sternum.

But let me tell you this now.  I would add a caveat to the acknowledge the first responder advice, and that caveat would be “Listen to them.”  I know sometimes in the past, while pretending to give my full attention, my mind has been going yadeedaa.

Now I say this because in my career, while I have had first responders or bystanders describe what seemed like crazy things compared to what my eyes were seeing when I arrived.  I have had those same seemingly okay patients suddenly revert back to what the bystander or first responder described.  “Sure, you were doing CPR, great Job!” I’d say, thinking that’s a laugh, only to find myself doing compressions five minutes down the road.  Or to have the responder describe the crazy seizure they witnessed, only to have the patient startle me with the same earth-shaking tonic-clonic  seizure later on down the road.

Don’t assume because the person is fine now, that they were fine when 911 was dialed.

I am not saying to take everything a first responder or lay person says as gospel, only to consider it.  Never dismiss any information outright. If someone says the little girl with the polka dot dress’s head spun around three times and fire came out of her mouth, I will store that nugget in a small, but retrievable place.

In EMS the hierarchy on a call goes something like this.  Bystander, first responder, EMT, paramedic, with each higher level of care assuming command as they arrive.  The hierarchy continues at the hospital.  Nurse, Doctor.  Although some of us paramedics would argue the nurse is not above us, most hospitals are structured where the paramedic turns the care over to the nurse, who makes the decision where the patient goes next – a regular room or a critical care room.

Has it ever happened to you where you have described the extremely sick patient you encountered who now seems fine, and had the triage nurse or the doctor be somewhat dismissive of your account because of what their own eyes are telling them?  I am sure it has if you have worked any amount of time.

Doctor, he was pale and diaphoretic.  Nurse, she was in full seizure.  Doctor, he was completely unresponsive.  Nurse, he was blue.  Doctor, I know it isn’t on yours, but I have ST elevation on my 12-lead.

Waiting room.   Or a bed in the hallway.

Later, you hear:  Hey your patient coded in the bathroom.  Or they found your patient seizing by the coke machine.  Or perhaps:  Yeah, didn’t you hear?  The hospital burned to the ground with only one survivor, a little girl in a polka dot dress standing in the midst of the rubble, unharmed

Old Friend

We used to (25 years ago) pick Darryl up every night around 10:00 PM.  He’d call from the pay phone on Barbour Street.  He was drunk and cold and wanted a ride to the hospital where they would put him in the waiting room and he would fall asleep in one of the chairs.  He could be combative with crews who gave him a hard time, castigating him for wasting precious 911 resources. Sometimes if he took a swing at an EMT, he ended up in jail for the night. I learned early on that it was easier to just pick him up and take him to the hospital than get all worked up about it.  Daryl was just a part of the night in the same way the battle ax triage nurse was.  You just dealt with him professionally and moved on.  

I remember one night, he called an hour or so early.  He wasn’t even drunk.  He held a Styrofoam box of chicken wings and fries from the local chicken place.  It was the night of the NCAA basketball championships and he was excited for the big game.  He sat down in front of the TV next to a couple of buddies and rooted for his team while chowing down on his chicken and fries.

He’d be a regular for a few years, then disappear only to reappear again a few years later, back on Barber street, calling from the pay phone that isn’t there anymore.  His disappearances coincided with stints in jail when his anger got the best of him or rehab if that’s what the judge ordered..

A few weeks ago, early on a Friday evening, I got called for an unconscious on Barber Street in front of the boarded up grocery store.  The fire department was there before me as well as an ambulance crew with two new EMTs.  The man was laying on the ground, clearly ETOH and telling everyone to F-off and leave him alone.  One of the EMTs tried to grab his arm, as he said “Let’s go, buddy,” but the intoxicated man jerked his arm away, and then took a wild swing that missed by so much, you couldn’t even consider it an assault. I was looking at him like I knew him from somewhere when it came to me.  “Is that Darryl?”  “Yeah, one of the firefighters said.  “He’s becoming a regular for us.”

I stepped forward and said, “Darryl, Darryl.  Is that you?”

He stopped swearing at the EMT and looked up at me.  There was a recognition in his eyes like he knew me from somewhere, but he couldn’t quite place me.  “I know you,” he said.  “Is that you?”

“It’s me,” I said.

“My my,” he said.  “I know this man.”  He held his hand up and I helped him up.

“Why look at you,” he said.  He turned to everyone and said.  “He and I went to rehab together!”  Then to me, he said, “Look at you!  Look at you now!  Oh! You’ve done well for yourself.  You’ve done well for yourself!”

He gave him a bear hug, and then looked at me again.  “You’re looking great,” he said.

“You’re not so bad yourself,” I said.  “You know why we’re here, right?

“Was I making trouble?”

“You just can’t sleep on the ground without expecting someone to call 911.  We just see if you’re alright.”

“I’m all right.  I’m glad to see you.”’

“You know where you are?”

“Barber Street.”

“Very good.  If you are able to walk away.  We’ll leave you alone.”

“All right.  I’ll be walking.”  Then he stopped and said.  “Look at you.  This here’s my friend,” he said.  “We were in rehab together.  He’s doing all right.  We both all right.”

Whether 911 was called again later, I don’t know.  He walked off under his own power, and I went home at the end of my shift, and told my wife the story.

If he did end up in the ER, I hope whoever took care of him, treated him okay, not getting riled by his rough manner, getting him some ginger ale and a sandwich and maybe letting him watch TV if a game was on, keeping him dry on what turned out to be a rainy night.

Falsehood Flies

 “Falsehood flies, and truth comes limping after it, so that when men come to be undeceived, it is too late; the jest is over, and the tale hath had its effect.”- Jonathan Swift, Gulliver's Travels

***

This week, the San Diego County Sherriff’s Department posted a video purporting to be a deputy overdosing after minimal contact with fentanyl powder and requiring naloxone resuscitation.  The story was picked up by newspapers all over the country, including the Los Angeles Times.

Authorities say San Diego County deputy overdosed after coming in contact with fentanyl

For the average reader, this is pretty scary stuff.  Now there is no doubt that fentanyl is responsive for hundreds of thousands of deaths.  But those deaths occur when users deliberately inject fentanyl into their blood stream, inhale directly into the nose, or ingest fentanyl contaminated pills.  People do this many times a day and rarely overdose.  The overdose is usually caused by disproportionate mixture of fentanyl in the powder or pill.  People are not dying merely from coming into close contact with fentanyl.  

There was a rash of these stories that began back in 2016 when the DEA released a two-minute video, Fentanyl: A Real Threat to Law Enforcement.  Jack Riley, the deputy administrator, opens the video by stating that “a very small amount (of fentanyl) ingested or absorbed through your skin can kill you.” He introduces two police detectives who describe their experience with a fentanyl exposure. One detective describes how, in sealing a baggie of the drug, some of it “poofed up” into the air, and the detectives ended up inhaling it. “I felt like my body was shutting down,” the other detective says. “People around me say I looked really white and lost color. And it just really felt like . . . I thought that was it. I thought I was dying. That’s what my body felt like. If I could imagine or describe a feeling where your body is completely shutting down, and, you know, preparing to stop, stop living, you know, that’s the feeling I felt.” The first detective adds, “You actually felt like you were dying. You couldn’t breathe, very disoriented. Everything you did was exaggerated in your mind, I guess. It was the most bizarre feeling that I never ever would want to feel again. And it was just a little bit of powder that just puffed up in the air.” Riley concludes, “Fentanyl can kill you.”

As I watched it, I thought about being a paramedic for more than twenty years. What they were describing didn’t sound like an opioid overdose. People who use heroin describe it as the most wonderful feeling they have ever experienced. They feel euphoria. The comedian Lenny Bruce described it as like kissing God. They give up everything they have to “chase the dragon.” What these detectives were describing didn’t sound like an opioid reaction; it sounded like anxiety.

The next year the DEA  released Fentanyl: A Briefing Guide for First Responders. It includes the following passage:

Personnel should look for any cyanosis (turning blue or bluish color) of victims, including the skin or lips, as this could be a sign of fentanyl overdose caused by respiratory arrest. Further, before proceeding, personnel should examine the scene for any loose powders (no matter how small), as well as nasal spray bottles, as these could be signs of fentanyl use.

Opened mail and shipping materials located at the scene of an overdose with a return address from China could also indicate the presence of fentanyl, as China-based organizations may utilize conventional and/or commercial means to ship fentanyl and fentanyl-related substances to the United States. 

I had to read the passage several times to make certain I understood it. I focused on one key phrase: “before proceeding” The DEA was saying that before treating a person with agonal respirations--someone moments from dying--emergency personnel should check the scene for packages from China.

I wrote in this blog, “If a patient is unresponsive and cyanotic, breathing two times a minute, unless they have fallen into a Scarface mountain of powder or any amount of powder that I think might compromise my ability to perform my duty of saving their life, I am going to put my gloves on, don my N-95 mask, grab my bag-valve-mask and start breathing for them. I am most certainly not going to wait to treat the patient until after I have scoured the cluttered room for hidden packages from China.”

The DEA’s warnings led to a rash of fake overdoses being reported as real, and one community in Massachusetts even spent $75,000 on a hazmat response where three people overdosed. 

The LA Times, in a story about a drug overdose scene in July of 2017, warned that “a small dose of the odorless white power can be fatal.” The story described the police response to an overdose call: “Officers have been trained to ‘back off’ when they come across white powder and an unconscious victim at the scene of a call.”  It was unclear from the article how long treatment was delayed to the three overdose victims, one of whom died. My hope was that medics, with proper personal protective equipment (PPE), were allowed to go right in to treat the patients. Police corporal Bertagna is quoted as saying, “A woman and three children were also found in the 800-square-foot apartment and removed.” Bertagna continued: “They, along with the officers and paramedics, all underwent decontamination, essentially an intense shower.” The fact that a woman and three children were alert in the same apartment suggested that the scene was safe.

 On July 27, 2017, the American College of Medical Toxicology and the American Academy of Clinical Toxicology had to issue a joint statement, Preventing Occupational Fentanyl and Fentanyl Analog Exposure to First Responders, stating that “the risk of clinically significant exposure to emergency responders is extremely low.”

I nationally known toxicologist I spoke with suggested you would have to sit in a bathtub full of fentanyl for an extended period of time for it to have any effect on you.  Transdermal fentanyl patches which are specially designed to provide medicine through the skin take hours to work.

I thought these stories had finally come to end and then the San Diego story surfaced.  You would think the Los Angeles Times would call medical experts and ask their opinion and then report it with more weight than a Sherriff claiming his deputy had overdosed on fentanyl.

Imagine a story in a legitimate newspaper.  Headline - BOY PURPORTEDLY ABDUCTED BY ALIENS, but the article has no scientific evidence of the abduction only quotes from board members of the UFO Society who  say aliens are responsible for hundreds of thousands of childhood and pet disappearances.  Buried in the article, a professor at MIT says, “the boy’s story is not plausible.”  Then the article ends with the boy’s father saying, “My boy would have died if I hadn’t grabbed his foot and pulled him out of that space ship.”  That’s about what happened with this story.

If you want to read more about this issue, read chapter 14, “Responder Safety” of my book Killing Season: A Paramedic's Dispatches from the Front Lines of the Opioid Epidemic, in which I discuss the issue of fentanyl safety.

The New York Times weighed in on the San Diego incident.

Video of Officer’s Collapse After Handling Powder Draws Skepticism

As of today, the Sherriff's office still has the video posted on their site despite demands that it be retracted -- a letter from a concerned group of health professionals, first responders, public health researchers, drug journalists, and people with lived experience.  (I am one of the 170 people to sign it to date.)

Retraction Request