origin Story

 

For many of us in EMS, our origin story began with watching the TV show Emergency. The decent paramedics Johnny and Roy, the wise Drs. Brackett and Early, and the beautiful unflappable nurse, Dixie McCall. Together they stood for all that was good in the world. They were role models for us in showing us a path to lead our lives as rescuers.

When we entered the workforce, or at later times, contemplated the other work we were doing, and wondered if there was something more meaningful, the example of Emergency was always there for us.

I came to EMS later than most. I was in my early thirties. I had been working in government/politics for a United States Senator, and with his defeat in 1988, I was at a crossroads. I liked the man I worked for – US Senator Lowell Weicker. He was a liberal Republican who was not afraid to buck his own party if he thought his actions would benefit the people of his state and country. He was a member of a group of moderate Republicans like Charles Mathias of Maryland, Jacob Javits of New York, and Ed Brooke of Massachusetts who crafted compromises both parties could live with. Sadly today, as William Butler Yeats warned in his poem “The Second Coming,” the middle did not hold.

“Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,”

Politics today is no longer about making good policy, it is about making political points in a battle for personal power. Everyone is partisan. Weicker was defeated by Joseph Lieberman, a Democrat who ran attack ads that distorted Weicker’s record, while Weicker preferred positive ads believing the people understood he was their champion. We didn’t know it then, but the world was changing. There was no FOX cable news channel then. No MSNBC. No internet. No Facebook or Twitter, but the seeds of the future were already being sown.

I never really cared for the political life. I could have stayed in Washington and became an aide to another Senator or joined an interest group or lobbying firm. Instead, I (full of beer and passion) announced at a going away party for the Weicker staff that I was going to become an EMT, and then having said it aloud, I had to follow up on it. And so began my EMS odyssey. Even when Weicker ran for and was elected governor and I worked on his campaign and served as a speechwriter and executive assistant at the state health department for his four year term, I continued to work as an EMT at night, while thinking about going to paramedic school.

The other day I came across a collection of quotes I had put together at that time (1992). The quotes represented what I thought about life at the time. They contained song lyrics, passages from books, poetry and culture, along with illustrations. I saw one quote I had forgotten about, one that I remembered finding in a book by the great oral historian Studs Terkel.

“The fuckin’ world’s so fucked up, the country’s fucked up. But the fireman, you actually see them produce. You see them put out a fire. You see them come out with babies in their hands. You see them give mouth to mouth when a guy’s dying. You can’t get around that shit. That’s real. To me that’s what I want to be.”

I worked in a bank. You know, it’s just paper. It’s not real. Nine to five and its shit. You’re looking at numbers. But I can look back and say, “I helped put out a fire. I helped save someone.’ It shows something I did on this earth.”

-Tom Patrick, Brooklyn firefighter quoted in Studs Terkel’s Working.

I believe that quotation, as much as all the episodes of Emergency, set me on my ultimate life’s path as an emergency medical responder. When Weicker left office in January of 1995, the next day I was on the streets of Hartford with a paramedic patch on one shoulder and an American flag on the other.

Now at sixty-three, in a world that seems to be threatening to fall apart, from the hateful politics of the our times, to the roof of my house, to my battered 200,000 mile plus sedan, to my own health no longer that of a young man, here I stand, still putting on my uniform and going in to work to answer the call.

I did seventeen 911 responses in a ten hour shift last Friday, and when I came home I just sat in front of the TV with my wife and daughter and ate a late dinner before going to bed to sleep the sleep of the weary.

I wish all jobs were like ours, where the oath is to do no harm, to help others, to make the world a better place.

Xylazone- Mind F

 Xylazine, a horse tranquilizer, has been increasingly found as an adulterant in the East Coast street supply of fentanyl.    In 2019 in Connecticut, xylazine and fentanyl were found together in 71 overdose deaths.  There were 141 deaths of this combination in 2020, and in 2021, through August with still many cases outstanding, the number has risen to 172.

In Puerto Rico dealers began mixing xylazine with heroin in the early 2000s. While xylazine has not been the subject of much human research and is definitely not approved for human use, it is believed to produce prolonged sedation and likely works synergistically with opioids to create a longer high.  This is significant because fentanyl has largely replaced heroin along much of the east coast, due to its economic advantages for dealers.  Fentanyl typically lasts 4-6 hours while heroin lasts 6-8 hours.  Fentanyl’s shorter duration requires people to use more often to fight off withdrawal.  It is speculated that xylazine’s longer sedative effects may help fight off withdrawal, and enable users to go longer between doses.  The high produced by xylazine with fentanyl also, according to some users, more closely produces the nod associated with heroin, which some users prefer to the potent fentanyl rush. Other users, however, seek to avoid it because it makes them feel like zombies, trapped in a haze that lasts for hours.

There are significant drawbacks to xylazine.  Most commonly xylazine, which may depress cells’ ability to handle oxygen, has been known to cause bad skin ulcers, as well as hypotension and bradycardia.  Xylazine may potentiate the respiratory depression of fentanyl and make someone more likely to die from overdose.  In other words, the xylazine may be enough to make someone severely respiratory depressed from fentanyl, completely stop breathing (not that fentanyl needs much help in this department), which will mean death if someone doesn’t arrive soon with naloxone to resolve the fentanyl induced respiratory depression. Some have said xylazine makes the user naloxone resistant, but I don’t buy that. Naloxone will still work on the fentanyl, enabling the person to breathe on their own, while still leaving them tranquilized with the xylazine.

If you are buying a bag of heroin/fentanyl on the street in Hartford, the guy taking your 4 dollars is unlikely to know whether or not there is xylazine in the powder.  An experienced user may be able to detect the presence of xylazine based on how it makes them feel.  It has been reported in Philadelphia that some dealers advertise the xylazine adulterated mix as “tranq dope,” but I have not heard that is the case here in Hartford based on my limited connections with users and harm reduction advocates. I recently asked a friend who now works as a bagger for a local dealer (in return for coffee, beverages, snacks, along with a low wage and discount on his fentanyl ($20 a bundle of ten instead of $30)), and he told me that his dealer does not use xylazine in his recipe.  He said that he has previously purchased bags from other dealers that he thinks likely had xylazine because they caused him to suffer severe ulcerations and also made him feel excessively tired and out of it.

His account squares with what we have seen on the street, and what we had previously believed might have been PCP mixed with fentanyl. (PCP while making some users crazed, leaves others catatonic.) One user called the fentanyl mix she was using “mind fuck” because it made her feel like she was trapped in her own body. Not being able to test the drugs they used, these instances could have been xylazine or they could have been some other unknown additive.

The bottom line is the drug supply is increasingly more dangerous, not just causing more deaths, but significantly harming users’ health as well.

While we offer users health services, naloxone and syringe exchange, if we are serious about lessening the deaths, we need to address the biggest culprit behind the slaughter — our toxic drug supply.  It is time to consider controlled legalization of pharmaceutical opioids.  Get rid of the poisons like xylazine and poorly mixed fentanyl batches, bring users in from the cold and allow them to use in safe injection facilities with medical and social services who can offer avenues to recovery.  If we truly believe our rhetoric that addiction is a medical and not a criminal problem, and we want to save lives, this is the logical next step.   

The Emerging of Xylazine as a New Drug of Abuse and its Health Consequences among Drug Users in Puerto Rico

Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature

Increasing presence of xylazine in heroin and/or fentanyl deaths, Philadelphia, Pennsylvania, 2010–2019

This Horse Tranquilizer Keeps Showing Up in Human Drug Overdoses

Graveyard

 I came to work the other day and saw a chilling site in the parking lot. Ambulance 911 — the ambulance that was assigned to me for many years when I worked the 5:30-17:30 shift, the ambulance that had been my EMS home — sat battered and wrecked in a line with other battered and wrecked ambulance and fly cars in our lot that at times seems like an emergency vehicle repair/burial yard. It sent a chill through me. (Fortunately, I found out the crew involved in the rollover accident was okay.)

EMS work is not safe. I know coworkers who wear bulletproof vests; others are meticulous in their infection control habits, always gloving and gowning up and washing their hands thoroughly. But if you really want to protect yourself in EMS, you should be wearing a crash helmet and a St. Christopher cross around your neck.

Here is a post I wrote back in 2006, describing an incident where I almost died. In the years since, I have had other close calls, but still nothing significant as far as ambulance safety or dispatch protocols has changed. We still travel lights and sirens too much, both to calls and from the scene to the hospital. Please be safe out there.

I Almost Died Today

Pediatric Posioning

You’re called to an urgent care center on a priority one.  The nurse is holding the front door of the center open for you and directs you back to a treatment room, where a PA and another nurse are providing ventilations to a two year-year-old.  The story they tell you is the the child fell off the couch and was not acting right.  His mother drove him to the urgent care center where they found the child somnolent and hypoxic.  The PA is questioning a head injury.  The child has no pertinent medical history and there was no seizure activity described at any time.  The child’s pupils are smallish, but equal under the bright light of the exam room.  The mother sits quietly in a chair in the room.  She can’t be more than twenty herself and seems detached from the emotion in the room.

You quickly reexamine the child and see no bruising.  While your partner straps a pedi-mate to the stretcher to secure the child, you take over bagging and find good compliance. The pulse oximeter probe you attach to the child’s toe shows a pulse saturation of 93%.  The child’s lungs are clear.  

While your partner drives, you and your student continue bagging.  You reexamine the child’s pupils, tuning off the compartment lights and using your penlight.  The pupils are definitely pinpoint.  You try 0.1 mgs of Naloxone through the IV your student has gotten in the child’s hand.  

My goodness.  Within a minute, the child is breathing on his own, his eyes are open and he is looking about the inside of the ambulance like he has been transported to a spaceship out of close encounters of the third kind.

You ask the mom, who is riding in front with your partner, if the child could have gotten into anything.  The mom you notice then is asleep, head nodded forward.  You reach through the cab window and shake her shoulder, “Hey!”  She looks up, half awake, as you ask, “Any chance the baby could have gotten into anything?  Any pills or powders about the house?”

She shrugs.  “What?”

“Are there any opioids loose in your house?”

She doesn’t understand.

“Heroin, Fentanyl, methadone, suboxone, oxycodone, percocet, vicodin, morphine, cough syrup…”

“I’m on suboxone,” she says finally.

“Okay,” you say,  “We’ll talk more.”

At the hospital she will talk with more people than you. The police department and the Department of Child and Family Services will interview her after the child tests positive for opioids.

***

In Connecticut, EMS responders are required by law to report all suspected opioid overdoses to the Connecticut Poison Control Center (CPCC).  In the last two years the CPCC has received numerous reports from EMS of children 3 and under overdosing on opioids, reports that have been confirmed by hospital toxicology lab results.  Positive tests have included fentanyl, cocaine, oxycodone, methadone and general opioid.  Additionally, the CPCC has also received reports from hospitals of similar cases where the parents brought the children directly to the hospital.  In 2020, two Connecticut infants died of fentanyl poisoning, including one who was found with a heroin bag branded “Skittles.”  

When responding to obtunded children in today’s world, medical professionals should always keep opioid poisoning at the front of their mind when considering their differential diagnosis.

Father Charged After Infant Overdoses on Fentanyl in Vernon

Doctors see alarming trend of kids brought into ER for drug overdoses, fentanyl in their system

In 2017, I wrote a blog post calling on dealers to stop using stamps with children’s characters on them and instead use skulls. Here is the link to Hello Kitty. 

Safe Supply

 In the last two days, there were two big news stories about famous people dying of suspected opioid overdoses.  One involved the death of one of my favorite actors, Michael K. Williams, who played Omar in “The Wire.”  The other was a triple fatal where the victims were believed to have used cocaine contaminated with fentanyl.

Actor Michael K. Williams, Who Played Omar on ‘The Wire,’ Has Died At Age 54

Comedian Fuquan Johnson among 3 dead after suspected drug overdose in Venice

The New York Times recently ran an article “The Cocaine Was Laced With Fentanyl. Now Six Are Dead From Overdoses,” which attributed a recent string of deaths to dealers deliberately lacing cocaine with fentanyl. 

 I believe they got it wrong.  From all the people I have talked to and most of what I have read, these cocaine deaths are more likely caused by cross contamination than deliberate lacing.  Many dealers, at least here in Connecticut, sell both fentanyl and cocaine.  If they fail to properly clean their equipment (grinders, sifters, scales, etc.), just the smallest trace of fentanyl can get into the cocaine and cause someone naïve to opioids to overdose and die if they are using alone or if there are using with a friend who is unable to give them naloxone or call 911 in time.

I have a friend, who the circumstances of his homelessness led him to a part-time job bagging drugs for a local dealer.  He packages both cocaine and fentanyl.  I asked him how likely was cross contamination to occur.  “Never,” he said, “We are very careful.  We keep both drugs separate.  Just the other night, I noticed my co-worker accidently put cocaine in the tray we reserve for fentanyl.  I spotted it right away, and we set it aside as contaminated.  We are very careful.  You can’t be killing customers with contaminated cocaine.  That’ll ruin your dealer’s reputation quick.  Of course, not all baggers are as careful as we are.”

Enough said.

If we really want to stop the deaths, we have to admit that people are dying from an unsafe supply, particularly from poorly mixed fentanyl.  Fentanyl tends to clump (my friend attests to this).  No matter how many times they put the mix through a sifter, the end result can still be a hot spot that can make a single $3 bag as lethal as a bullet to the head.

Packaging houses are not FDA approved. They are do not have quality safety standards.

Talk all you want about getting rid of fentanyl, it is not going to happen.  We have never been able to get drugs off our streets.  There are more and far worse drugs on the streets today than when the War on Drugs began back in the 1970s.  Prohibition doesn’t work.  Instead of following the same failed policies, if we are serious about lessening the deaths and ending the slaughter of far too many Americans, we need a new approach.

I am all for harm reduction, but it can only do so much.

I now believe we need to decriminalize drugs and replace our dangerous unregulated street supply with safe regulated drugs.  We do this with alcohol, we do it in many states with marijuana.  We do it with methadone and suboxone.  We should do it with other opioids.  In Canada, they have been successful with a pilot program that treats opioid addiction with dilaudid. 

Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction

We need to try approaches that work.

Stop the deaths.  Replace what’s killing people with a safe, regulated drug supply.

Paramedics Indicted

 I have been a street paramedic since 1995.  Up until 2008 I often worked 70 hours a week.  That’s when I got a part-time job as an EMS Coordinator at a local hospital.  In that position, I do quality assurance on the paramedic services that we oversee.  I stayed full time as a medic, working Sunday through Tuesday 12 hour shifts, and then sat at the desk Wednesday to Friday.  Two years ago, they bumped up my hours at the hospital, and for a while I worked 20 hours on the ambulance, but now I am down to Fridays in the city fly car, responding to 911 calls all day.

I like doing both jobs.  Working in the street keeps me honest.  On Monday I read another paramedic’s run form and wonder what he was thinking.  On Friday, I find myself in the same situation and better understand what that medic was thinking.  I am always reminded, it is never straight forward.

When I heard of the case of Elijah McClain (the young man who was by many accounts was assailed by police officers simply for acting strangely, and then medicated by paramedics with Ketamine, and shortly after went into cardiac arrest and died), I wondered about what actually happened.  Since I was reading about the case for the first time on a Monday, I had my EMS Coordinator hat on.  I read that the boy was given a Ketamine dose of 500 mg while he only weighed 143 pounds.  The dose for Ketamine in Minnesota was 5 mg/kilogram (kg), while in Connecticut, for those services who carry it, it is 4 mg/kg.  Elijah McClain received the dose for a 220 pound man.  How did that happen? Paramedic math, I guessed.  I see it often.  5 X 100 is 500 which is how much is in the vial.  When it comes to pain management, I see the same thing with Fentanyl. 1 X 100 is the math for Fentanyl with its dose of 1 mg/kg and comes in a 100 mg vial.  Reading the run forms, many patients it seems weigh 100 kgs.  Ballpark the weight. 100 kgs. Yeah, that’s it. Give him the full vial. No need for math than than. Possibly lazy medics, I thought. 

Then I get out on the street and I am reminded of the other side.  It’s not that easy to accurately guess someone’s weight.  Sure there are cases where you can ask the patient, but as any medic will tell you, people aren’t always honest about their weights and often are not in condition to have a reasonable conversation.  I have calculated a person’s weight in the middle of a scene and then later seen the person stripped of all their clothes in the ED bed looking quite smaller.  Same with ages.  I did a bad car accident once where I thought the patient was in their early twenties only to later find out he was was twelve.  Why wasn’t I at the pediatric hospital! And I did the opposite, transporting a traumatic arrest, thinking the patient was 12 only to find out she was in her twenties. Sometimes we work in chaos.

Recently I had to sedate someone who was running in circles, doing gymnastic somersaults on the hard pavement, slamming himself to the ground, then getting up and doing it again. He was sweating heavily, talking in voices, and then fighting when we tried to get him onto the stretcher.  I use Versed as my sedation agent because the service I work for doesn’t yet carry ketamine (It’s on the way I’m told).  Our Versed dose is 5 mg for adults, wait and then give another 5 mgs if necessary 5 minutes later.  No need for math.  We used to be able to give 10 mgs right off the back.  I don’t like the 5 and wait 5 minutes.  Waiting may look good in a protocol meeting, but when the patient is beating the crap out of everyone, it seems unreasonable. 

This guy was on the smaller side as opposed to some of the patients of linebacker size with prison muscles we get on PCP.  I gave him 5 mgs.  He was still fighting when we put him in the back of the ambulance.  The crew wanted to tie him down and the cops wanted to accompany us.  No, he’ll be asleep in a few minutes, I said.  Let’s just keep him calm.  I like to turn off the lights and say nothing and just passively push back their blows.  I was already thinking I was going to give him another 5, but this guy was asleep within seconds of my statement.  A minute later I was bagging him to support his declining respirations and get his carbon dioxide down to a reasonable level.  I bagged him all the way to the hospital, where he ended up getting intubated and going to the ICU. (He ended up just fine, thankfully though I never found out what drugs he had on board beyond my suspicion of cocaine). The point I am getting at is you can sedate 10 people; each will react individually. It’s not like baking a cake. In EMS, the same recipe can have different results.

I don’t know what happened to Elijah McLain.  What did the medics see when they arrived? Did they do easy math and give him a dose that turned out to be lethal for him? Or did Elijah die because of something the officers did? Or was it a combination of many other different elements? I do think it is hard for prosecutors to hold paramedics criminally liable for a death unless they have worked street calls themselves and better understand the conditions and variables, the variables of a call. And most importantly, they have evidence of malignant intent or gross negligence. I’d like to see these medics have a jury of their peers.

I don’t have the information to convict or exonerate them.  And I don’t disagree with prosecutors that Ketamine (and other drugs we carry) can be considered a deadly weapon. Our EMS drugs can be deadly if not used carefully and with proper medical justification.

I will watch the trial closely and hope that justice is served. 

As an EMS coordinator, I will  work to have the best, safest protocols for our medics to work under, and when questionable cases are brought to me, I will try to see them through the medics’ eyes, based on my own experience.

As a medic on the street, I will continue to try to do what I believe is best for my patients, while working within the scope of our medical protocols/guidelines.

No one ever said being a medic was easy. Do the best you can.  Know your protocols.  Use sedation with caution.  Act on your patient’s behalf.

And if you are ever indicted or called before your EMS Coordinator/QA person, tell the truth, help them understand what you saw and why you did what you did.

https://abcnews.go.com/US/wireStory/elijah-mcclain-investigation-announcement-expected-79767107