Kelly is as dispirited as I have seen her. “My veins are shot,” she says. “I can’t even get high.” IV users use 1 cc syringes which have a very small needle they only need to slip inside the vein. When they pull back and get blood they know they are in. They push the plunger slowly, sending the heroin directly into their vein and right into their circulation where quickly delivers its powerful payload to the brain. This is a faster and stronger route than swallowing a pill or inhaling the powder in through the nose. If however, the needle in not anchored in the vein, the drug goes into the tissue where it can cause damage and necrosis. The user still gets an effect, but it is less strong and comes at a price in damage to the tissues.

Kelly has shown me her veins before and they are challenging. I fancy myself an expert at inserting intravenous lines. I may be an average medic in some skills, but I am really good at IVs. I have been doing IVs for twenty five years on all types and ages and races of people.
There is a difference between doing an IV as...

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She finds him in the bathroom at seven in the morning and knows immediately he is using heroin again. Three weeks ago, they moved east from Seattle. She had a job offer and it also represented a chance to get him away from his junky friends. After three times in rehab, she didn’t think she could go through it with him again so she was thrilled when he agreed to move with her. They got a nice loft downtown, with plenty of light. It was close to her job, and from across the street, he could get a city bus to any job in the area he could find. If was convenient to many things – a minor league ballpark, movie theatres, riverside park with running trails, a health club within blocks. He was always in good shape, but he particularly worked out hard when he was staying clean. Her new job was going to keep her busy, but there were plenty of restaurants they could go to at night, along with a comedy club and local brewpub. They’d make friends, and in time, if he started working and got a steady position, they could get up a down...

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The man is trembling, sitting on the bed in the spare motel room down by the highway. Sometimes, these rooms are filled with the patient’s worldly belongings, but this room seems to only have the bed, a dresser, a chair and the TV. The man is in his fifties, a portly man with white hair and liver spots on his hands. The Spanish woman in the room with him is of an indeterminate age. She wears a pink tank top and grey yoga pants with flip flops, even though it is cold and blustery out. She is the one who called. When I say she is of indeterminate age, I mean she could be anywhere from 30-50. It appears she is missing a fair number of teeth and her arms lack the tone of a younger woman. While he talks to us, she walks behind him and mimics a man shooting heroin. He says he is a diabetic and hasn’t eaten or taken his insulin for a couple days. He says he got robbed last night and has no money. He is going to have some transferred up to him tomorrow. We check his sugar and it is 485. The normal range is 80-120. 485 is in the danger zone. If he doesn’t take...

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The man is on the nod, the only thing keeping him up is the fence he is leaning against. When the police officer tries to extricate him from the fence, he falls back and the officer has to lower him to the ground. I set my red bag down to get out my ambu-bag, but I can see the man is still breathing regularly. I shake his shoulder. He opens his eyes. No need to get out the Naloxone. I lift him up under his arms, while my partner grabs his legs. We get him on the stretcher. He nods back out. We find an orange capped syringe in his left front pocket, and some white powdered residue in a small plastic baggie in the right front pocket. The officer gets the man’s ID out of the wallet he finds in the man’s back pocket. He says he’s going to run his name for warrants.

We wheel the patient over to the ambulance and load him in the back. He is SATing at 97% and his ETCO2 is 48. The ETCO2 slowly climbs into the 50’s as he starts to hypoventilate, but with a little shake, I stimulate him enough to get it back down into the 40’s. While waiting for the officer...

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Does access to naloxone influence an opioid user’s decision to use?

That is the crux of a recently published (on-line) economics paper, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, which argues that increasing access to Naloxone sanctions risky behavior, unintentionally increases opioid abuse, leads to greater crime, and may increase the death rate.

The paper has generated a great deal of controversy. (The authors have rewritten some of their paper to accommodate some of these expressed concerns.)

The moral hazard of life-saving innovations: Naloxone access, opioid abuse, and crime (Blog Post)

The ‘moral hazard’ of naloxone in the opioid crisis

Why a Study on Opioids Ignited a Twitter Firestorm

Research Analysis: Conclusions about ‘moral hazard’ of naloxone not supported by methodology

Their underlying assumption seems to be that naloxone creates a safety net whereby opioid usage will increase because users have less risk  knowing if they overdose they can be revived. The authors...

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One of my EMS coworkers and a budding journalist Sean Freiman interviewed me recently about Hartford’s Opioid Crisis with a focus on the heroin bags.

Click on the picture to view the interview.

Should unresponsive overdose victims receive rescue breaths or chest compressions from lay bystanders?

If a person is apneic but not in cardiac arrest, failing to give rescue breaths may lead this person to fall into cardiac arrest.

But, if the person is apneic and in cardiac arrest, failure to do quality chest compressions, will lead to their death.

This is a difficult question that we debated in our opioid overdose working group last year. We chose to follow the American Heart Association standards and tell lay rescuers to do chest compressions in apneic patients rather than attempting rescue breathing.

Chest compressions-only are simple, easy to learn, and backed by science.

I like the chest compression for the lay public because:

Chest compressions while providing some circulatory support also provide passive ventilation. *
Chest compressions are also a great stimulus to revive someone from an apneic state.
Most people don’t do rescue breathing very well.

The Ontario Canada Ministry of Health debated the same...

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Overdose on Babcock Street. In an alley behind a building. Fire is there before us. A familiar scene. As I approach I can see them hunched over the patient, the bag valve mask out. They have already given her four of narcan. I stand over them looking at the patient. I can’t see her face because the mask obscures it, but I notice that she is quite tiny. I look at her neck then and can see the butterfly tattoo sticking out from under her winter coat. It is Veronica. I last saw her a month and half ago, and had wondered what was going on with her. Did she go back to Woodbury to stay with her sister as she always does when she tries to get clean? Or had she died alone in an alley such as this one? At least I know she is alive. I have the firefighter stop bagging for a moment, and can see while she is still unresponsive, her respirations have picked up. The ground is cold, so we lift her up onto our stretcher, and then bag her on the way to the ambulance. We load her in back, and I barely have her hooked up to the capnography, when she opens her eyes with a...

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Opioid deaths are generally classified as accidental overdoses. In 2017 Massachusetts began reporting opioid deaths as “All Intents” where they previously reported them as “Unintentional/Undetermined.” They point out that adding suicide deaths only marginally adds to the count. By their statistics only 2 percent of the total opioid deaths were confirmed as suicides.

Massachusetts Opioid Death Data

Connecticut reports opioid deaths under the term accidental drug related deaths. If a person left a suicide note, and then injected themselves with heroin, they would not count in the state’s totals.  In most cases, it is hard to say with determination the overdose was a suicide.

An article published on March 28 in Medscape asks “How many Opioid Overdoses Are Suicides?” It offers fairly persuasive arguments that the numbers are much higher than reported.

How Many Opioid Overdoses Are Suicides?

Dr. Maria Oquendo, the past president of the American Psychiatric Association, is quoted as saying based on published studies, the suicide rate could be...

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I recently participated in a project to describe the daily routine of an EMT to help people considering a career in EMS.  The final product was published this week on the website below.

INSIDE LOOK AT LIFE AS AN EMT

Here is an excerpt:

5:30 AM:

I punch in and checkout my equipment, my house bag which contains my medications, IV and airway supplies, my heart monitor, and then the equipment on the ambulance shelves, while my partner checks the ambulance to see that the siren and emergency lights are working and that we have plenty oxygen to make it through the shift. He also checks the oil and engine fluids.

Then, we sign on with our dispatcher and already there is a 911 call for us. No time for coffee. A 68-year-old woman has been vomiting all night. I feel her forehead she is burning up. Her tongue is also dry and cratered. I give her Zofran for her nausea and IV fluid for her dehydration. We transport her to the hospital.

6:23 AM:

I am writing my PCR (Patient Care Report) on my laptop computer in the hospital EMS room when my pager...

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