Waiting for Corona

 

Connecticut is up to 11 confirmed cases, but none in the Hartford area yet. This is a bit misleading as my understanding is very few people have been tested in our state (The Hartford Courant reports 136 have been tested) due a shortage of test kits and the start up time it takes new labs to set up.

I worked in the city today and it was quiet. The hospital waiting rooms were not crowded at all, which is unusual. I saw a Park Street bus go down the street with not a passenger on it, but the streets weren’t empty. The same people who always stand on the corners were at their posts. There was plenty cars driving about, a few with masked drivers.

Before we went on the road we had to checkoff our protective gear – two full isolation packages, four N95 masks, surgical masks, two eye protection glasses, decon wipes, and hand sanitizer.

I talked to two homeless heroin users today. One said she was very worried about the virus. She said she was trying to wash her hands whenever she could; the other just shrugged. Corona was the last of her concerns. She still needed a few dollars to buy her next bag of dope.

My last call of the day was for a woman with a sudden onset of body aches, chills, and nausea with dry heaves. Her skin was hot and her heart was banging away at 120. She had no foreign travel, and no one she knew was sick. I asked every question I could think of to elicit some information that might reveal that she met Corona criteria, but I struck out. I gave her some fluid and four mgs of Zofran. I suppose if she ends up having had COVID-19, someone will be letting me know.

The foreign travel question is going to have to change with all the reports of Americans getting Corona without any foreign contacts. Pretty soon, the question is going to be “Have you left your house at all in the last 14 days?”

At one of the hospitals this afternoon, the ED staff was screening two people in a car. The passengers each had mask ons, and the doctor was fully gowned up with a face shield, and the nurse had a N95 mask as well as full body protection. The doctor had a clipboard and the nurse had a portable BP machine out by the car.

When my shift was over, I stopped by the large Chinese supermarket by our office. The place was sparsely populated with a noticeable number of shoppers wearing masks. I bought some barbecue pork, green vegetables (snow peas and bok choy), dried noodles, and frozen dumplings. Yesterday I went to the local stop and shop and it was in full scale panic. The governor had outlawed any gathering of 250 or more people, but I tell you there were five or six hundred in that store. No chicken. No frozen vegetables. No toilet paper. I didn’t see a single mask.

I’ve been buying steady so we are in good supply at my house. Tonight we stay home and watch TV together.

It may only be a few days till Corona is in our town.

Protective Measures

 Our Corona response all comes down to this graph:

 

Source: New York Times

All the cancellations, social distancing, self-isolation, hand-washing is about slowing the inevitable spread of the disease so the health care system is not overwhelmed.  

Years ago I worked on a factory assembly line and the ideal was for the line to go a little bit faster than you were comfortable with so you could achieve maximum performance.  If the line went too fast, hit the breaking point, then everything fell apart.  The line spiraled out of control.  People just stopped and gave up as parts fell off the line and what product did get assembled  was done so badly, it had to be rejected.  We can't let that happen to our health care system.

Without protective measures, people will die who otherwise wouldn't have.

Breach

 

COVID-19 has breached our state borders. There are four confirmed cases in Connecticut.  I was supposed to fly to Washington today for a federal opioid conference, but the University of Connecticut president issued a decree cancelling all domestic travel for its faculty and staff. (1,2) The governor weighed in two days later and cancelled all domestic travel for state employees.

While I was looking forward to the conference, cancelling the trip at least spares me the horror of having a coughing fit on the plane and ending up being escorted off the plane by men in space suits and quarantined on some obscure naval research base.  

I worked the ambulance Monday.  Twice, I was screened on entering a building on a call.  One was at the VA, where three masked nurses asked me if I had any flu symptoms or had traveled out of the country.  I got the same questions at a nursing home, but they sort of let us through as they were soon overwhelmed by fire and police responders all racing past.  

My first patient had a fever, a cough, nausea, vomiting and diarrhea.  But she hadn’t been out of the country for sixteen years and probably hadn’t been out of her home hospital bed for at least that many months.  Another patient had a fever, but he had a septic hip, and also hadn’t been out of the country or had contact with anyone suspected of having COVID-19.

I washed my hands a ton of times.  I ponder. If a hospital has a five month supply of Purell, but because of Corona fears, people are using Purell five times as much during the day, doesn’t the hospital just have a one month supply?  I did run across a couple empty wall containers today that hopefully got refilled.

I didn’t work for a week so I was curious what the feel of the street was as far as corona.  Washing hands. Yes. Wiping down the stretcher. Not so much. I tried to make certain to strip the stretcher after each call and wipe down the straps, but I didn’t notice a great change in people’s habits.  

We didn’t get a whole of Corona training.  We had to watch a fifteen minute or so video on-line  that was pretty boring. That said, every year we get airborne pathogen training and there is nothing in there that is different with Corona.

Talking with others, the lines I heard the most were “The flu has killed more people this year than corona,” and “It’ll just be like getting a cold, I’m not afraid.”

My younger co-workers have no fear, which I also didn’t when I was their age.  The older medics, like myself, are more concerned. At 61, I am according to some sources, supposed to be staying at home to protect myself.

We also received the CDC guidance.

Interim Guidance for Emergency Medical Services (EMS) Systems

We just received this notice today from the state:

New guidelines from the CDC recommend that instead of N95 surgical masks, health care workers can use looser-fitting face masks to shield themselves from contracting the coronavirus, a change prompted by an ongoing shortage of the N95 respirators. The virus is primarily spread by droplets, and the agency is narrowing its recommendation for the use of N95 masks to workers dealing with severely ill patients.

So the change to the lessor quality of protection is due to a shortage, not to safety.

A friend of mine (not much younger than me)  told me he was worried we are going to run out of masks.  He said his wife told him if that is the case, she will forbid him from going to work.  But honey, he said, I have to work. He is the breadwinner and I don’t think he has cash reserves. I am worried that in our country people will hide their sickness because they can’t afford to miss a paycheck.  

Lebron James the basketball great said the other day “I aint playing if the fans aren’t allowed to attend the games.”  He says that’s who he plays for. I don’t expect him to be a public health expert to understand the threat of corona or the importance or slowing the transmissions.  I’m watching a sports show on the TV now and they are talking about how much money it will cost the NBA owners if they have to cancel or put on games without fans in the stands.  I understand the owners and players may lose some money, but we are talking ants to giants here, sports to global wellness. The economic cost to the world and all people will be much greater if this virus is not kept under some type of management.  Not to mention the human cost. We may only get a cold, but if it gets passed to enough older people, many of them will die who otherwise would not have. We need to protect our frailest citizens. That outweighs watching the NBA playoffs, and I am a basketball fan.  Go Celtics!

I have heard some employees from our company who were exposed to COVID-19 out west have been placed in self-isolation.  I was reading what self-isolation is about, and while each article is different, they share some common themes.

You have to stay in your house.  If you order pizza, the delivery man has to leave it on your doorstep.  You are not supposed to go outside (leave your property). You should stay in one room. Ideally with your own bathroom.  You shouldn’t go for a run in the woods. You might give corona to the raccoons.  

Again I ponder.  What do the homeless do? 

I read we should be using credit cards rather than passing bills which may contain the virus.

I usually carry a few spare dollars to hand out to people in need.  Should I stop?  I handed out some dollars on Monday.  I hope I didn’t pass any germs.

I’m back at work on Friday.

We’ll see what the day brings.

***

1. My daughter also had her sixth grade basketball state championship games this weekend cancelled.  They had made it to the semi-finals. All high school sports championship tournaments were also cancelled.  Curiously the UCONN basketball team traveled out-of-state to play in a capacity arena and there is no indication they won’t go ahead and play in the upcoming March Madness, including likely hosting games on their campus.  We’ll see what happens when public health meets NCAA dollars.
2. I’m on the hook for a night’s hotel stay.  My trip was being paid for by the federal government, but I had to use my credit card to guarantee the reservation, and would only get paid back later when I submitted the receipt.  I was smart enough to get insurance on the airline ticket, but I had to tolerate three hours in the phone line waiting for an operator due to all the corona flight cancels, “Celebrate,” "Hello, "It’s Me," and Fleetwood Mac’s “Gypsy” and about four other easy listening songs on a loop that I must have heard 20 times before a blessed human voice finally came on (she was very nice when I finally got to talk with her).
3. I think in those areas where police, fire and the ambulance all respond to 911s at nursing homes, maybe they should limit the response to just the ambulance.  It is rare that anyone beyond the ambulance crew is needed, and surely two people entering is safer than eight for both the patients and the responders.

Corona Cough

 I may have mentioned before, I have a bad chronic cough. I have had it all my life. I can go all day without coughing, and then I get a hunk of phlegm on the back of my throat and I just have to cough, and often it takes me five or six coughs to get it clear before I am fine again. These are not little dainty coughs. These are earth-shaking put your hands down on the counter, lean over and hope you don’t pass out coughs.

It is rare that I don't have someone come over and ask me politely “Are you all right?”

That was before Corona.

I am at work at the hospital and headed to lunch at noontime. In the elevator, I feel a cough coming on. Just before the door closes, a leg sticks through, and it reopens to admit a young nurse. I smile at her, doing my best to hold my cough in. It is only two floors. I hold my breath and then I hold the door for her and as soon as she is by me, I bolt to the corner of the hallway and cough into my arm, and for a moment, I am alright. A close one.

The cafeteria is crowded like a watering hole on a scorching day. I make my way through the throngs to the salad bar, still feeling a bit of an itch in my throat. I get a plastic bin, and no sooner have I put two leaves of lettuce in it, than I feel the urge to cough come roaring back. I drop the salad tongs and retreat to the coffee machines, and try to collect myself. But no matter how hard I fight it. I can’t hold it in. I cough once hard into my shoulder.

The cafeteria falls quiet.

Ears perk.

It is like a herd of deer has lifted their heads. Not a movement.

Could a wolf be about?

I move quickly several steps to my right, and try to hide behind a man carrying a tray with two cheeseburgers and a large order of fries on it. I cough again. There is a fluttering through the room. The cheeseburger man bursts forward quickly, and I am left naked in the open. Heads swivel, searching for the perpetrator. Two women eye me. One whispers to the other. I see a man point toward me, eyes narrowing. They are all focusing on me. I fear someone will shout “There’s he is! There’s the cougher! He's going to kill us all! Stone him! Stone him!”

If I take another breath, I will cough uncontrollably.  My eyes will water, my face turn purple!  I can't let that happen.   I still hold the salad bin in my hand. I calculate if I can make it to the register. Not a chance. The lines are too long. Still holding my breath, I turn, put the bin with the two leaves of lettuce in the garbage and flee back out the cafeteria entrance. I flee down the hall, then into the elevator, which thankfully is empty. I go back down the two floors to the basement, and flee down more long halls until I am safe in my basement office where I sit in my chair trembling.

Oh, man. 

Devil Around

 

Police in Holyoke, Massachusetts are warning about a new heroin mixture that may not respond to naloxone,  It allegedly produces violent reactions in its victims. The mixture contains the synthetic cannaboid MDMB-4en-PINACA .

Holyoke police warn about new drug mixed into heroin that causes ‘violent’ behavior, may not respond to Narcan “

The article is misleading in its assertions about the possible ineffectiveness of Narcan. Narcan may not cure this overdose, but if the person is violent, they do not need Narcan. If they were unresponsive and received Narcan and are now violent, then they responded to the Narcan. Narcan works on opioids, not on cannabinoids. Cannabinoids usually do not cause respiratory depression or respiratory arrest, which is the indication to use Narcan.

Here in Hartford, dealers have been adding PCP, among other substances to the heroin/fentanyl they sell. We have seen people with violent reactions post Narcan that could be due either to their annoyance at being suddenly put into withdrawal or it could be due to other devilish substances that are now unleashed now that the patient is conscious.  More typically, the heroin users I have had who overdosed and also had PCP onboard, returned to maintenance breathing, but were often catatonic. One of the users called the drug mind-fuck. Others have complained of racing hearts -- we’ve seen heart rates in the 160s-200s, as well as the bizarre behavior associated with PCP and other disassociative and mild altering drugs.

Instead of treating these patients with Narcan, we use Versed or Ativan, benzodiazapines that sedate the patient.  We get a lot of experience with this as PCP overdoses, at least in the north end of Hartford, are more prevalent than heroin.

Two points behind all of this.

Naloxone works on opioid overdoses.  There has yet to be confirmed evidence of an opioid that does not respond to naloxone.

There are some nasty substances being added to heroin.

What do we do about it?

I think it is time a city in the United States provided medical grade heroin to users in supervised injection sites, and follow how these users do over the course of a year. How many die? How many developed endocarditis or skin abscesses?  How many are arrested for violent behavior or other crimes?   How many got into rehab?

No only our our fellow Americans dying in unacceptable numbers, they are being poisoned by the additives dealers are adulterating their opioids with.

Medicinal grade heroin has worked in England. We should try it here.

Legal Heroin Prescriptions: The 'British System' You Never Knew Existed