Saturday, January 19, 2019

Dancer

  

I first picked Veronica up on Hungerford Street one afternoon two years ago. We had been called for an unresponsive, but instead, we found a small woman with a club foot staggering along the street.  She was half on the nod and covered with leaves. I asked her if she was okay, as we walked up.  She just mumbled, and tried to keep walking. We stood in front of her and at twice her size, it became hard for her to ignore us. We were called, we have to at least see if she was okay, we explained.

"I'm fine," she said.  "I just want to go home."

"Why are you covered with leaves? I asked.

She wiped tears from her eyes.  "The kids robbed me and threw me in the bushes.  It happens all the time.  They like having their fun with me."

At least she seemed to have managed to buy and use some heroin before they accosted her. Her pupils were pinpoint and she had a weakness in her knees while standing. Perhaps the kids had been warned by the block enforcer not to rob her until she had contributed her few crumpled dollars to the day’s take.

"You don't hurt anywhere?"

"No, I just want to go home."

She was under the influence, but she was breathing fine and knew where she was when prodded. She let my partner do a head to toe survey on her and he found nothing significant. 

We couldn’t talk her into going to the hospital, but we did walk her the two blocks home to her apartment building where a neighbor who saw her walking with us agreed to look after her.  She told us she had narcan in her apartment.

After that day, whenever I saw Veronica on the street, I would have my partner pull the ambulance to the curb and I’d call out, “Hey, Veronica, how are you?”

She’d come to the ambulance window and we’d chat. I learned some things about her.  She was thirty-eight.  When she was little she wanted to be a dancer, but her bones were too brittle to stand up to the stress. She had once gone to New York to see Swan Lake on Broadway and she had ice skated at Rockefeller Center.  She turned to pain pills and then heroin for her bone pain and for other health reasons, which she did not elaborate. She said she stayed away from white heroin because she was afraid of overdosing on fentanyl, which had already happened to her twice, waking up looking at the paramedics. She snorted and did not inject as she was afraid of needles despite the butterfly tattoo I could see on her neck.  She stayed away from Chief, KD and the Fastrack brand. She made certain to keep narcan in her house and tried not to use alone, although she admitted she often did.

Last February we were at the substance abuse rehab hospital, waiting for a nurse to let us into the locked unit to take out a patient with a low 02 sat, when I saw Veronica come out of the entrance elevator and walk up to the admission desk. She was very pale and moved like every bone and muscle in her body was aching.

“Veronica,” I called over to her. “How are you doing?”

She looked about the room trying to locate the familiar voice. She likely wasn’t expecting to be recognized there.  When she saw me she forced a smile and nodded.

“Glad to see you,” I said. “This is your time. You can do it.”

She looked down at her feet, her face flushing. I wasn't certain if she was pleased I'd said hi or if  I had embarrassed her.

That was the last I saw of her for many months.  And then, just before Christmas, I spotted her walking alone on Park Street early in the morning. We pulled over and I called out her name. She came over, her head barely up to the window. When I asked her where she had been, she told me she had been staying with her sister in Woodbury, but then she had slipped up. Now she was back in Hartford. I told her I was proud of her for the months she’d been clean, and that she shouldn’t be discouraged. Relapse is a part of recovery for many. She did it once, she could do it again. The next time would be the charm.

"Thank you," she said.

I reached in my pocket and took out a Dunkin Doughnuts gift card. I always keep a few on me to give to homeless people. “Merry Christmas,” I said, than added, “It’s only for $5.”

Her face softened and she gave me a huge smile. She took it with one hand and with other, she reached for my hand, and gave it a squeeze. “Merry Christmas,” she said.

I watched her hobble down the street and wondered what her Christmas would be like, if she would be spending it with family and friends or if she would celebrate it by snorting a bag of heroin alone in her apartment.  I wished I had given her a few bucks to go with the card or maybe the orange I had with me.

I try to follow the users I encounter and see how they are progressing with their lives. Some I see regularly on Park Street; others disappear. I don’t know if they die or if they recover and are living productive lives or if they are just using on the streets of another city.

I can’t see the future, but every day people are still alive should be counted as a small victory for them, even if they fail in the end.

I still see Veronica around the neighborhood, and sometimes we talk.   I saw her this week on Park Street. It was a bitterly cold morning.  She was with three guys wearing hoodies, who I always see in front of the same shuttered store. She was doing a wobbly dance for them, prancing around, turning circles and waving a scarf in the air. She laughed and the dealers laughed too. They seemed to think her dancing was really funny like she was their court jester. They motioned for her to dance more, and she responded, flapping her arms like a butterfly.  I had a brief vision of her then just flying away, rising above Park Street, and migrating on to a better place.  The vision faded and all I saw was the men laughing as she stumbled.

My partner asked if I wanted him to stop so I could say hi to her, but I said keep driving.

Muscle Rigidity in Opioid Overdose

 

I wrote a number of months ago about fentanyl induced chest wall rigidity in opioid overdoses.

Chest Wall Rigidity

Fentanyl induced chest wall rigidity is rare in the hospital setting, but it should not be surprising to find it is a factor in overdose outside the hospital given that the amounts of fentanyl being injected are exponentially larger than in the hospital.

A typical $4 bag of properly mixed fentanyl sold on the streets of Hartford can be the equivalent of 1000 mcgs of fentanyl or 10 100 mcg fentanyl vials.  A bag with a hotspot of fentanyl would obviously have considerably more.

Since I wrote that post I had no further instances of possible fentanyl induced rigidity despite doing many ods.  That is until several weeks ago.

The call came in as a seizure in a restaurant that was closely associated with narcotic activity. We found the patient sitting awkwardly at a table at a table, looking almost like he was having a dystonic reaction. He was very stiff. His head was turned slightly to the left. One of the fire department responders said, “He’s on something.” The patient's pupils were pinpoint. He could react to stimulation and even say a few words, but he was too out of it to communicate with. We were able to stand him up, but we couldn’t get him to lay on the stretcher. When we finally picked him up, it was like picking up a cardboard cut-out of a man.  His legs were completely stiff and did not fall down with gravity. Out in the ambulance he was breathing at rate of six a minute and his ETCO2 was 99. His SAT was in the 80s. I got an ambu-bag out and started assisting his respirations. I did not meet much resistance, but I had difficulty getting significant chest rise, even after repositioning him a few times, and finally laying him flat. I palpated his chest, but it felt like a normal chest. My partner had given him 0.5 Naloxone IN, followed by a 2nd dose four minutes later. Only after she got an IV and gave him an additional 0.2 mg Naloxone IV did I begin to see chest rise and the ETCO2 began to drop. A few minutes later he woke up, and after initially denying he used any drugs, admitted that he had sniffed a bag that he told us must have had fentanyl in it. His respiratory rate was now 18 and his ETCO2 had dropped into the 30’s and his sat was 96%. We transported him, he had no further complications and was released from the hospital after a couple hours observation.

This week I read a new article, Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada, published in the Harm Reduction Journal. During the seven month study period Staff at Insite, Vancouver's supervised injection site, responded to 1581 overdoses, and documented 497 of these people having abnormal reactions, including 240 with muscle rigidity. The authors' write:

“Muscle rigidity ranged from jaw clenching to decorticate posturing with arms bent in towards the body, legs held out straight, clenched fists, and overall stiffness.”

In the article, they correlate the rise in abnormal reactions with the rise of fentanyl in the local drug supply.

Their conclusion:

"As the drug supply is increasingly contaminated with fentanyl and other synthetic opioids, overdoses may present with atypical features with or without other typical opioid overdose characteristics. It is important to recognize that muscle rigidity, dyskinesia, slow or irregular heart rates, confusion, and anisocoria may be observed as part of overdose presentations and should still be treated with naloxone and oxygen."

You can read the entire article here:

Harm Reduction Journal: Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada

Bottom Line:  If you encounter a seizing patient, a patient with muscle rigidity or a patient who may just seem hard to bag, and if you suspect that patient may have just used opioids, treat with naloxone.

***

Another fascinating tidbit from the article. Only 15% of these overdoses were transported to the hospital. In Hartford, almost 90% of our opioid overdoses are taken to the hospital with most being released from the ED either AMA or discharged after a couple hours monitoring. At the Vancouver safe injection site, after giving naloxone, the staff observes the patient right there in the facility. There were no deaths at the facility during the study period.

 

 

Sunday, December 23, 2018

Manual Versus machine Blood Pressures

 

How do you want to be known as a Paramedic/EMT?

A. Reliable
B. Frequently wrong

According to a recent article in JEMSDitch the Machine to Improve Accuracy in Blood Pressure Measurement and Diagnostics, "automated blood pressure readings are frequently inaccurate."

Is this a surprise to anyone?

Yet, many of us continue to relay on automated BP cuffs to direct our clinical actions.

In a March 2016 article in the Journal of Clinical and Diagnostic Research, Which is More Accurate in Measuring the Blood Pressure? A Digital or an Aneroid Sphygmomanometer:, digital devices:

  1. should be used with caution, doubt and suspicion
  2. are not up to standard
  3. (can cause many people to be) wrongly or misdiagnosed
  4. may prove disastrous

Powerful words.

The JEMS article points out that even the manual for the Physio-Control Lifepack 15 contains this warning:  

"shock may result in a blood pressure waveform that has a low amplitude, making it difficult for the monitor to accurately determine the systolic and diastolic pressures."

Got that.  Your Lifepack 15 is not capable of providing reliable blood pressures if your patient is in shock.

Cardiogenic shock
Hypovolemic shock 
Anaphylactic shock 
Septic shock 
Neurogenic shock

Your machine BP is unreliable when addressing these conditions.  It is frequently wrong.

How are you going to make clinical decisions with bad data?

You need to take manual blood pressures.

As an EMS Coordinator, I see run forms with blood pressures like these:

158/71
210/190
143/84
95/87
170/119

All for the same patient.  With no explanation.

As a paramedic, I have had my patient in afib brought into a level one medical room because the triage BP machine said my patient had a blood pressure of 79/40.   Why are we in here? the doctor asked as he looked at my calm, warm, dry patient.

Because the triage system at this hospital relies on digital blood pressures. 

Don't relay on machines to take a blood pressure in patients with atrial fibrillation.

Here are my guidelines:

  • Make your first blood pressure manual
  • Treat your machine pressures as an inexperienced partner
  • Before making a critical clinical decision, take another manual pressure.

Make certain you know how to take a proper blood pressure.

Here are some good articles to help us improve our manual blood pressures:

Taking a Manual Blood Pressure: Techniques & Pitfalls

Blood pressure reading tips and tricks for EMS

 

I get it.  It is hard and nearly impossible sometimes in EMS to obtain optimal conditions for taking a blood pressure.

Just know that the blood pressure you obtain under those impossible conditions (using short cuts) may not be accurate.

Don't let inaccurate and unreliable readings cloud your clinical judgement.

Take a manual, and if you can't hear, palpate a blood pressure.

 

 

 

Tuesday, December 18, 2018

Balance

December 8, 2018: This weekend, I am in Worcester, Massachusetts at the New England Short Course Meters Masters Swimming Championships as a member of the Connecticut (CONN) team. Last year, we shocked many of the other teams by taking first place. Points are awarded based on place finish in individual and relay events. Each swimmer is only allowed to swim a maximum of six events a day or 13 for the entire meet. Friday evening is distance day (800 Free), Saturday and Sunday are for the relays and the main swimming events. Last year I scored 119 points swimming 12 events despite having a pretty severe chest cold. I also swam in three of the four relays. I came in second in the men’s 55-59 200 Meter Butterfly and earned 15 points for it. I was second out of 2 swimmers. Last year I finished 25th in the nation in that event in my age group. 25 out of 25. Still I was proud as it is a difficult event, particularly for someone who did not know how to swim the stroke five years ago. I am swimming it again this year, and if all scheduled swimmers swim, I will likely finish 5 out of 5, but maybe some of them will scratch (drop out) as it is the last individual event. Last year I swam the full 200 meters without stopping. This year I may hang on the wall and catch my breath at some point along the way. I have not trained as much this year as last. My best event is the 50 free, but I will not come close to my best time of two years ago. Again, lack of training time and intensity. Plus Father Time sapping some of my strength.

Joe Frazier used to say. “If you cheated on that (your roadwork) in the dark of morning, you’re going to get found out now, under the bright lights.” I have no cold this year, but I am a year older, and not in the shape I used to be. That lack of training is likely to be apparent. Still I am here as part of a thirty person contingent of people who I have come to call my friends over the years. No matter how fast or slow I swim, i always get high fives and good jobs. I doubt we will win this year. Charles River Masters, who we upset last year, showed up loaded with more swimmers. My goal is to score more points for my team than last year, which will be a little easier as I am swimming one additional event and I have moved up in age to the 60-64 division.

Here’s why I writing all this on my EMS blog.

I was talking the other day with a new medic trainee and we were talking about a number of the old career medics who were around when I started, and I told her of how many of them ended up broken. Here’s a roll call. Overweight, fired for poor behavior, dead of a heart attack. Fired for violating policy, seen a few years later in a nursing home with jaundice, dead not long after. Retired unceremoniously, dead within months of lung cancer, obit posted on the operation’s wall. Fired for undisclosed reasons, shot dead by police in a standoff -- suicide by PD. Left for undisclosed reasons, found dead in bed a few years later, obese, uncertain of heart attack or overdose. Not a lot of happy stories. Many say that the job will leave you bitter in the end.

I used to say that I wanted to stay at this until I am 72 when my youngest daughter is targeted to graduate from college. I don’t know if I can make it make it that long. I am hoping to at least stay full time until my middle daughter who is a freshman at college graduates. My goal is to get her through without any debt. In addition to my medic job, I also work as an ems coordinator at a local hospital. Between the two I am scheduled for 64 hours a week, but I often work longer. I try to keep Saturdays as a day for my youngest daughter and I to do things together.

My youngest is very into sports, and unfortunately, tomorrow, she has her first basketball game of the season, and I will miss it because I am here at the meet. She is playing in two leagues this winter, one with Saturday games and one with Sunday. Other than today, I will be at all her Saturday games, but because I work Sundays, I will only be able to see the Sunday games if I take off work. A part of me wants to go part-time on the ambulance so I can be free to see all her games, but with the middle daughter in college, I can’t really afford that yet. I debated not going to this meet, but last year I skipped several meets to see her games. The fewer meets I do it seems the less I train. This is the one big meet of the year, so I expected if I skipped it, my identity as a masters swimmer would pretty much slip away, and I am not yet ready to give that up. I need athletic competition to keep me healthy and maintain my image of myself as an athlete and a man still in prime health.

All these conflicts.

I used to never miss an ambulance shift. I prided myself on always being on time and always being there if my name was on the books. In twenty-five years I have only had to go home sick twice, and only called out sick about the same number. I have only been late three times, twice due to a time change and once due to my alarm not going off. I take days off fairly freely now. With my seniority, I get a ton of PTO, so I use it. I took off for Zoey’s soccer championships and I will certainly take off for her basketball championships if she makes those. My next swim meet is Superbowl Sunday and I am planning to take off for that, but only if it doesn’t conflict with one of her games. I’ll take that game over the local meet. Hopefully, I’ll be able to do both.

I enjoy my swimming friends, as I enjoy my EMS friends. And of course, I enjoy my family most of all. Between the three I hope to be able to maintain a balance that I have not always had. I don’t need to be on the ambulance everyday or at every swim meet or at every single one of my daughter's games. I just have to do my best to be there whenever I can, and ensure that I am healthy, and happy. I want to be there for the long run.

Postscript:

We came in 3rd in the meet. I had the eighth most points of any male in the competition, points mainly accumulated because I was one of a few who swam 13 individual events. I finished the 200 Butterfly only a few seconds slower than last year, and captured 3rd place. Out of 4.

My daughter won her game and scored 8 of her team’s 14 points. Hearing her recap of the game wasn’t as good as being there, but it was still great. Nothing much of interest happened on the ambulance that day, according to the guy who filled in for me, nothing unusual. I didn’t miss out on anything exciting.

The meet renewed my enthusiasm for swimming, so I have been hitting the pool hard this week. I saw my daughter’s game yesterday and it was great. They won and she played well, scoring 10 or 12 points in the win, including making both her free throws. Not bad for 10 years old.

I am at work now, posted on a street corner in the December rain, drinking hot tea with honey.  I am hoping the next call will be an interesting one.  I hope that I get out on time so I can swim at the pool.  I hope that when I get home, I will sit in my armchair and have a cold glass of water, while my wife sits on the couch and laughs at Will Ferrell in the Wedding Crashers in a way that brings warmth to my heart.  I hope that my daughter will be dribbling her basketball back and forth between her legs.  I hope that she looks up at me and says “Dad-Catch!”

 

  

Thursday, December 06, 2018

Not My Addiction

 

This is great film, made by EMS for EMS, to help us understand addiction and the stories behind our patient's lives.  The 37 minute film tells the story of four addicts in their own words, including one who was once in EMS.  Listening to these four tell their stories helps people understand how easy it is for a person to fall into the grip of opioids and how hard it is to get out.  As I mentioned in another blog post, I recenly heard a mother describe her daughter's descent into opioids, which ended in her death, as "an innocent entry and an impossible exit."

I met two new young people this week who were ex-addicts struggling to reclaim their lives.  One was a former army medic, who told me he became addicted in Afghanistan. His squad often found caches of heroin, hidden by villagers. It was hot there and they were always hydrating themselves with IVs.  One day they added a few grains of heroin to the IV.  Three days of this and he found himself coming down with a horrible flu.  It took awhile for him to realize he was in opioid withdrawal.  When he came home, he found himself in Hartford, a land where a bag of heroin is only $4.  Two years of hell later, and scared by two fentanyl overdoses, he finally got on suboxone, which is working for him.  Still he's a homeless vet, and he has a long way to go to truly be back home.

The other young man got hooked on prescription pills after an injury.  He followed the usual course, buying on the street when his prescription ran out, and switching to heroin because it was so cheap.  The death of so many of his friends got him onto methadone, and that too, is working for him, although like the soldier, he is homeless and living in the woods.  We talk for a long time, and I tell him how my views on addiction have changed over the years and how I now recognize it as a disease.  "You should talk to my parents," he says.  

Watch the film.  Educate yourself.  Talk to people.  There are a lot of lost souls out there who can use our help.  

Not My Addiction

Review: Documentary film takes EMTs, paramedics inside the pain of opioid addiction