Suffering in the World

 We are sent to a detox center for a diabetic. We find a sixty-year old Puerto Rican with a blood sugar over 600, although he has no complaint. He has come to the center to kick his heroin habit. But first now he will have to go to the ER to get his sugar under control. I did three bags of heroin this morning, he admits, then I flushed the rest of the bundle down the toilet, and came here.  He is a man with deep eyes. He speaks quietly. I spent eighteen years in prison, he says. When I came out, I saw there was so much suffering in the world. People on the outside are used to it, and they don't see it, but I saw it. That's how I got started. I've been on and off of it for most of my life.  He tells us how he lost two brothers to heroin and a sister and two cousins to crack cocaine. My father died at ninety last week. He was all I had left. I was lost without him. It was a setback for me, but I looked at myself this morning and knew I wouldn't see seventy if I didn't get a hold of myself. I knew it was time for me to come in.

At the scene of a motor vehicle accident, a wife yells at her husband who has driven his new Toyota into a parked car. He called her and gave her the address so she could bring his insurance card. The address isn't in the best part of town. After she leaves, he waits with the cop for the tow truck to come. The cop thinks something isn't quite right with him, and asks if he is a diabetic. He is, he says, so the officer calls us to check him. He looks to be in late thirties. He wears blue jeans and a college athletic sweat shirt. His sugar is 43 a little on the low side. His answers to questions are slow. He can't remember if he ate or how the accident happened. When I go to roll up his sleeve to look for a vein, he at first refuses. I have issues, he says. We don't care about that, I say. He has track marks on his arms. I put in an IV and give him some sugar that clears his mind up. He looks at the front bumper of his car which is all mashed in. Driving along and he veers off the road. I wonder what he's thinking now. Maybe I should have stayed home. Maybe I should have had a sandwich before I shot up. I wonder up the road what lays ahead for him. I don't think he has thought about that yet.

A wife comes home from work and finds her fifty-year old husband on the kitchen floor, semi-responsive with vomit on his face, chest and the linoleum. His skin is cool. She calls 911. He recently had shoulder surgery and is on blood thinners for clots in his legs. She has no idea what has happened or how long he has been there. When we arrive, we find he can answer questions. He is not hurt, his grips are equal, there is no facial droop, but his speech is slow. He looks at his wife and says Sorry. I ask what meds he is on. I'm thinking maybe he has taken too many and maybe drank, although I can smell no liquor on his breath. He seems familiar to me; not his face, but his whole manner as we pick him up. We are in this new freshly built home, a large sparse home with hardly any furniture, but he seems just like a homeless man in his demeanor. Here is this guy with a well dressed wife, and he seems in his faded jeans and grey tee-shirt and flushed face to be just a street man. He looks up at her and again says, sorry. We get him up on the stretcher and as we start out the door suddenly I hear the wife say, Hold on a minute. She has found something in the bathroom. Heroin.

She is beside herself, she is so angry. The officer asks her if this is something he regularly does.
"No, He's been clean for almost sixteen years since before I met him. He's been very upfront about his past with me, but I've never seen it. He doesn't even drink. I can't believe he did this. I could kill him.

It's the most addictive drug in the world, the officer says. No one ever completely beats it.

I just can't believe this. I'm in shock.

She comes to the hospital with us, riding in the front. Is he okay? she asks.

He's stable, I say. He'll be all right.

She cries. He's been so depressed, she says. He lost his grown son two weeks ago. He's been out of work with his injury. He's had no money. We have a new home and with him not working, we can't afford to put anything in it.
He's beaten this before, I say, He can do it again. Don't be too hard on him. It sounds like he's had a rough go.

I could just kill him, she says, but not as harsh this time.

After we leave them in an ER room, I come back later and glance in. She sits next to his bed, leaning against him, her head against his shoulder, his big arm around her. He brushes her hair. Neither of them speak.

***

I first posted the above ten years ago. No easy street solving this problem.

***

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Diamond in the Rough

***

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Opioids for Chronic Pain

 Should paramedics give opiates to patients with chronic pain?

I want the answer to this question.

Now, until recently I have not questioned this practice. Today, I still medicate (well, most*) patients with chronic pain of 4 or more, who do not have contraindications, and who say yes when I ask them if they want pain medicine. I am following our regional pain guidelines, which I helped write. Underlying the guidelines in the premise that pain is what the patient says it is, and human suffering should be relieved.

Today at one of the hospital EMS rooms, I saw a flyer for a CME being offered on February 10 at a local ambulance service (Windsor) about pain management that included a mention of when it was appropriate and when it is not appropriate to give a a patient opiate pain meds. My question! It sounded like an absolutely first rate CME, which unfortunately I can't make because I will likely still be at work on the ambulance when the CME kicks off. The flyer mentioned a virtual guest speaker, Dr. Ruben Strayer. I googled the guest speaker and found this fascinating lecture that questions giving opiates for chronic pain. Now while his lecture does not get down to the paramedic level, it does touch upon the ED MD.

Pain, Compassion, Addiction, Malingering: How To Use Opioids (and how to not use opioids)

Having only listened to it once, it boils down to this.

Big pharma funded a huge effort to convince doctors that opiates are harmless, so people were overprescribed opiates, and this created a generation of addicts that has wreaked havoc on our nation as the opiate epidemic is killing more people today than motor vehicle accidents and destroying families and millions of lives. I wrote about this recently in Pain Myth.

And key to my question, Strayer says giving opiates for chronic pain may in fact be harmful for patients, and while providing temporary relief, may cause hyperanalgesia (where opiates actually make patients more sensitive to pain), and it may further their dependence and make them sicker. There may be better alternatives, he suggests. He breaks down the risk strategies that an ED MD should go through before giving opiates. Perhaps such a model could be developed someday to help paramedics decide who to administer opiates and who to defer treatment to the ED.

Here is an except from the web page about the talk:

For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment.

If opiods may be harmful in the ED setting, then maybe they are harmful in the prehospital setting. If they are, I don't want to give them.

I am not ready to change yet, and before I change, if I become convinced of a better way, I will try to change our paramedic treatment guidelines at the same time. I want to hear what other doctors who I respect think of Strayer's ideas and the general issue, and I, of course, want to read more about this topic.

Two points to make clear. Strayer is not talking about acute pain or about cancer pain. Both of those categories are clearly appropriate to treat with opiates.

As a footnote, in his talk, he mentions the possible benefits of ketamine for chronic pain, and he also says marijuana may be better and less harmful for someone with chronic pain than opiates. I have been in EMS many years, but doubt I will be around long enough to light a bong pipe for a patient in the back of my ambulance. Strayer, of course, is not advocating this either. But a prescription for medical marijuana may in the future replace percocets as the take home prescription of choice.

Bottom line, it is a provocative talk, and as an almost militant pain management advocate, it caught my attention.

*If I believe a patient is outright lying to me, I may withhold medication. The same with if the patient has been identified to me as a patient who an ED does not want getting opiods, then I will withhold. In general, I have always erred on the side of the patient and given the opiate.

Little Things

 The other day I wrote a post called "Burnout" that was a scathing critique of the working conditions of urban EMS. I sent it to a friend to read before I posted it, and he called me up, and said "Dude, you are crispy." I ended up not hitting Publish, even though I really wanted to. The piece was very well written, full of great metaphors and passion. But,, fortunately, good sense got the better of me (I have a commitment to to try to avoid whining on this blog) and the post remains in my draft folder.

So instead of publishing "Burnout" today, I am publishing "Little Things." Here's two little things that are keeping me going.

I have written before about how much I love my Fort Lewis boots.

New Boots

But better than Fort Lewis boots are Fort Lewis boots with these excellent thick wool socks I have. My feet are so comfortable. I love my thick wool socks. I'm just walking along thinking, man these socks are comfortable! It doesn't get much better than this!

The second thing is my Starbucks coffee thermos. Now I don't go to Starbucks and I don't drink coffee. The mug was a Christmas present. Until recently I was a Diet Cokehead. About two months ago in an attempt to get rid of my cough (likely caused by post nasal drip), I switched to ginger honey tea (which fights against phlegm). I made the switch cold turkey and it went great. Now I have hot ginger honey tea to start my day. In the afternoon, I switch to a cold ginger honey drink. Its awesome and my cough is much improved.

I go to work with my thick wool socks and my thermos of ginger honey tea, and I think, urban EMS life isn't so bad. I think I can make it though another the day. Bring it on.

Drug Addicts

 The heroin epidemic is getting a lot of play in Connecticut. In 2015, according to the latest numbers there were 415 heroin deaths in the state, triple the number three years ago.

There is a bill in the legislature to require all first responding agencies in the state to carry naloxone. Here's a news article about it:

Narcan Bill Draws Early Support in Connecticut

There is some controversy that this may be overkill and too costly as you would have the potential for, in some cases, four responding agencies all showing up on the same scene with their Naloxone ready to go. Not everyone would use theirs, and the drugs would expire and need to be replaced, at quite the hidden cost as the price of Naloxone continues to skyrocket and the availability has at times been scarce.

You could make an analogy to defibrillators. So what if all four agencies carry defibs? The first one there is the one to use it, and the sooner the better. Naloxone is a little different. If the agency has a bag valve mask and two people (or one skilled in one man bagging), they can breathe for the patient until the Naloxone arrives.

According to the above news article, the state police have saved 65 lives using Naloxone. My guess would be they have used it 65 times. That does not always correlate to a life saved. If the police breathe for the person, the Naloxone will show up eventually. And as we in EMS know, Naloxone only works on living people. Once someone's heart has stopped, Naloxone does not restart it.

In Hartford, neither the fire department nor police department have Naloxone yet (that I know of), although I know at least the Fire Department will be getting it soon. They often beat us to the calls, and are usually doing a great job of bagging the patients prior to our arrival. I am all for them carrying it, and taking care of the problem before we get there. If I had to choose between police and fire getting Naloxone, I would want the police to have it because they often arrive first, and I haven't seen them use a bag-valve mask for years. And they can recognize when someone needs it. I step out of the ambulance, the officer usually says, 'you're going to need your Narcan.'

On these two calls, police and fire were at the first scene before we were. Young woman is unresponsive in a parking lot with agonal respirations. We think the boyfriend called 911, but it might have been a passerby. While the woman is cyanotic, and breathing at 4 a minute, she comes to with stimulation, and we decide the Naloxone is unnecessary. She admits to doing a bundle of heroin (10 bags) -- a little more than she usually does. She had given herself a strong dose, but hasn't quite overdosed. Her lethargy is what she was seeking. We put her on capnography and give her a little shake if she starts to nod off too much. We have conversation with her on the way to the hospital. She has been using heroin for years. She is also on methadone, but she missed her daily dose at the dispensary that morning. We ask her how she got started on heroin, and she says she started with prescription opiods following spinal fusion surgery. She got hooked on them, and when she had a hard time getting enough to ease her pain and addiction, heroin was cheaper and easier to find. She keeps asking us where her pocketbook is. We say her boyfriend has it. The officer on scene gave it to him. We think once the boyfriend knew he wasn't being arrested, he offered to hold the pocketbook. The girl is quite upset that he has her pocketbook.

"But he's your boyfriend,' we say, "He called 911. He saved your life."

"You can't give him my pocketbook," she says.

"Why not?"

"We're drug addicts!" You morons.

She asks again at the hospital about her pocketbook, and then asks if her boyfriend is there yet. Nope, no sign of the boyfriend. She starts wailing. She knows him better than we do.

The second call is at a public restroom. It comes in as a cardiac arrest. Based on the address, I say it is going to be another heroin overdose and I am right. Another kid in his twenties from the suburbs goes into the restroom and doesn't come out. A maintenance man had to open the door with his key. The kid is lying on floor, cyanotic to the max, breathing two a minute if that. We have beaten fire there. The police officer who was there first doesn't have Naloxone or a bag mask.

In the end it doesn't matter. We get our bag valve mask out and give him our Naloxone and he soon comes around.

"I don't need Narcan," he says.

"We already gave it to you. You were blue."

He curses.

His story is he and a buddy came in to the city to score. He says he only did one bag and hasn't used for a while. I am not certain I believe him. We ask him how he got started. Motorcycle accident. Broke his leg in multiple places. Did you get put on Percocets? I ask. Six months worth, he says, then he cut me off. His buddy doesn't ask for his wallet, but on the way to the hospital, he looks in his wallet and shakes his head when he sees it is empty.

Here's what I think. I am all for the widespread availability of Naloxone. Give it to the addicts; give it to their families and friends. Give to any first responding agency that thinks they will use enough to merit stocking it or who is willing to pay for the one life they may save.

Both these addicts were in their middle twenties and they looked horrible. Ghost white complexions, jittery, hollow eyes, bad teeth, scarred limbs. They are not alone, there is an army of them out there. It reminds me almost of the walking dead. People want to know how the epidemic started and who started it?

We have to look at ourselves, the health care system. Most of these people had normal lives. They got hurt, and they were put on terribly addicting drugs by doctors they trusted, and doctors who likely thought they were doing the right thing. Not everyone put on a six month course of Percocets for their injuries became an addict, but plenty did, and the drug destroyed them.

415 died in Connecticut last year. Did they all come to heroin the same way? Probably not. Each had their own story. But there is a clear pattern. And their stories all end the same. The way things are going the number will likely be higher this year. The walking dead are on our streets.

Footprints

 Three sets of footprints in the snow. Two with fully defined treads. Mine barely register. I’m twelve years older than the two of my partners combined. This is my fifth pair of boots and the soles have gone smooth. I walk carefully. We do a call and I can’t make it up the icy driveway. I keep slipping down the incline. I have to hike up through the snow to get to the door. I have had this pair of Fort Lewis’s seven years, and they have stood me well. I order a new pair that night and they arrive on Christmas eve. I put them under the tree so I it will look like there are even more presents when my daughter awakes in the early hours and checks to see if Santa has come. In life we give way to youth, all of us do. We fade away. But I hope this new pair of working boots won’t be my last. I have more earth to tread on, more inclines to climb.