Be well. Practice big medicine.

Heroin flashbacks

TAOS5I pushed Narcan the other day. The first time in over four years.

Some of you may be thinking “So what.” or “Big deal.” Or even the more derisive “Big Whoop.”.

However, having provided EMS for the southern half of Santa Clara County and the City of San Francisco for over two decades where we used Narcan, almost by the gallon, this was a familiar flashback.

Heck we gave it so many times back then that as an EMS system, we had gotten into the habit of “hot shotting” it. Bypassing the formality of establishing an IV and just injecting it directly into the patient’s veins.

And for those of you who may be cringing at this, we were not a system out of control. Just efficient and expedient. Or so we liked to say. However we drew the line there. Unlike our brother & sister medics across the bay who developed the habit of giving Narcan sublingually by injecting it through the bottom of the patient’s jaw.

But I am digressing.

Last week’s run was a simple call really. We responded to the only trailer court, actually the house trailers, single and double-wides, are spread out over a ridge side. But when your jurisdiction is a glacial valley high up in the San Juan Mountains, that counts as a trailer court.

Getting back to the call, our intrepid local visiting nurse was checking up on one of her charges, a broken down cowboy and former champion team roper, a healer, who is only a few months older than me, when she noticed something was amiss. Actually Altered Mental Status.

Seems our cowboy had a medical history somewhat akin to that children’s song, “I know an old lady who swallowed a fly”. He had a degenerative back disorder that in turn led to immobility, which in turn led to the development of multiple bed/pressure sores and hot spots.

One of which had been recently debrided almost down to the bone and he had a suction pump on over the wound site.

In turn he was prescribed a Fentanyl patch for pain control and after the debridement, also placed on Oxycontin, among other things. This is a Reader’s Digest version of this man’s med history but enough to set the stage.

So it seems that our cowboy was in significant pain and this particular morning he took not one but two of his Oxycontins. AKA, Hillbilly Heroin.

The prescription drug that conservative right wing radio commentator Rush Limbaugh became hooked on. Along with hundreds, if not thousands of North Americans north and south of the 48th parallel over the years.

Our patient was one we had seen numerous times over the past three years for a variety of problems. AMS secondary to alcohol to a fit of depression where he shot up his trailer court and held off emergency responders for several hours before being talked down and allowing us to transport him to the hospital. He was always initially angry on first contact but once we were able to talk our way through the anger, he was actually quite a charming and affable fellow.

This time he was in a recliner, snoring respirations of two to four with a room air sat of 61 percent and rouseable to moderate physical stimuli. Once roused he was lucid for 20-30 seconds but if left unstimulated, drifted back down to unconsciousness.

At my suggestion, my volunteer checked our patient’s pupils, one of the most frequently overlooked or fudged patient assessment signs, and, you guessed it, they were pin point. My EMTs thought I was genius.

Yeah, right!

Truth is that I am just an old medic who has the benefit of working 20 years in the San Francisco Bay area, the heroin capitol of the US. I, like all of my bay area medic brethren and sistren have assessed and treated more opiate overdoses, straight up or in combination with other substances than you can shake a stick at.

As our volunteer EMTs and driver placed our cowboy on high-flow oxygen, which brought his oxygen sats up into the 90s, fantastic when your elevation is between seven and eight thousand feet, dozens of my former patients flashed before my eyes.

Like the time I was a new medic and was trying to figure out why my female AMS patient with pin point pupils had a huge wad of ice shoved down the crotch of her panty hose. Or the multiple times we had been called for the unknown medical eval in a hallway of an SRO apartment building only to find one, two and sometimes more patients, all in respiratory arrest and AMS.

It would turn out the patients had been in a “shooting gallery” and received a stronger dose of Heroin than they were used to. The fine operators of the gallery would dump the unfortunate user in the hallway or out on the sidewalk and call 911.

Probably the best war story about this type of call occurred to a brother San Francisco Dept. of Public Health Paramedic, Mike Tregassor, aka Tregasourous, back in the early 80’s.

Back then, after three in the morning, the City of SF would go down to five ambulances until the day units would start coming inservice at 05:30.

It was a busy night and all the other units were tied up on runs. Sound familiar?

Anyway, Mike’s unit was dispatched to an apartment code two for a medical eval. Mike and his partner arrived and received no answer when they buzzed the apartment number at the door. Dispatch was unable to get anyone to answer the callback number.

Being resourceful medics, they went down every apartment number on the door panel until they were finally able to rouse one of the other building occupants to let them in. They trudged upstairs to discover the apartment door partially open.

Pushing the door open after no one responded to their knocking, they discovered that they had not one, but five patients scattered about the apartment. All unconscious and not breathing or grossly hypo-ventilating.

A shooting gallery that had the misfortune to be using a new shipment of Heroin that was stronger than the local junkies were used to.

My partner and I were just unloading an assault victim at San Francisco General Hospital when we heard Mike come across the air stating he had five H-ODs and needed at least two additional ambulances.

Dispatch acknowledged his traffic and then informed him that there were no available units and that they were on their own.

My partner and I just looked at each other and then informed the triage nurse that our patient was stable and that we had to go and we beat feet to the ambulance to back Mike up.

Mike in the meantime, I’m sure uttered a word or two of frustration but then became medic brilliant. He and his partner came up with one of those innovative solutions that they just don’t teach you in EMT or paramedic school.

They dragged all the patients to the middle of the apartment and arranged them like spokes on a wagon wheel. Heads towards the center and feet out to the periphery. Mike’s partner got out their only bag-valve-mask device while Mike hooked it up to their portable oxygen. The partner, I wish I could remember his name, then crouched in the center of the patients and ventilated each patient with two breaths before going on to the next patient.

Mike in the meantime ran back down to the ambulance and grabbed all the Narcan on the unit, which was a lot. He returned in time to help his partner disentangle himself from the oxygen supply tubing and continue to ventilate each patient in turn.

Mike then hot-shotted each patient with Narcan in whatever vein was most prominent. Whether it was the traditional anticubital, AC, or the less conventional external jugular. Every patient received 2-4 mg of Narcan.
Mike later stated that if he had needed to do CPR on all the patients, the way they had them arranged, he could have just literally jumped from chest to chest around the circle. Fortunately, this wasn’t required.

The Narcan got all of the patients breathing again on their own. Two of them even woke all the way up. When my partner and I arrived we were greeted by the elevator door opening and Mike dragging a still unconscious, but now breathing patient by his collar and the two other patients who were now awake sort of assisting two other semiconscious patients.

We supplied some additional Narcan and helped transport all of these very fortunate folks to the hospital.

Ten years and dozens of Heroin overdose calls later, I was working the night watch with Vicki, my bride of now almost 24 years and sister medic.

In addition we had a ride along that evening. Lance Wright, an Auckland, New Zealand paramedic and friend, who was visiting the Bay area and was spending part of his vacation riding with us.

It just so happened that a new shipment of Heroin had hit San Francisco that weekend and we were dealing with H-OD after H-OD the previous two nights. The hits just kept on coming.

I happened to be driving that evening and Vicki was attending, when we received a call for an AMS, possible H-OD in the 4th floor hallway of a Chinatown walkup apartment building.

We arrived ahead of the fire department but there were several police cars on scene. And of course the elevator was out of service. As we took to the stairs we heard a woman screaming and looked up to see a police officer’s head pop over the banister and tell us the patient was not breathing. The head disappeared and then reappeared a second later with the statement.

“Oh my God! I can’t believe my partner is giving him mouth to mouth!”

This had to be bad if the cops were doing a lip lock on a patient. So we chugged our way up 4 flights of stairs to find one officer with a screaming woman, she turned out to be the patient’s wife, and a large unconscious male laying in the hallway outside of their apartment.

Lance lets out one of those cheery Commonwealth statements along the lines of “Oh goody, I’ve never seen Narcan given before.”

We quickly explained as we started bagging (ventilating) the patient that we weren’t going to give it right away. That the reason opiate overdose patients had the reputation of coming up combative after Narcan administration was not that we had ruined their high. It was hypoxia.

Opiates work by slowing everything down including the patient’s respiratory drive. Opiate OD’s die not because the drug kills them directly. Those patients who are found dead with a needle still in their arm, were not killed by the opiate, but rather what the drug had been cut with. Like Strychnine or something else equally unhealthy.

Deaths due to the opiates occur because the patient’s metabolism and specifically respiratory drive have been slowed down to the point where they just forget to take their next breath. This is why your classic opiate overdose is AMS, weak, thready pulse, pinpoint pupils and either apneic or hypo-ventilating.

So we ventilated our patient with 100% oxygen. In the meantime we introduced Lance, who was wearing his New Zealand Ambulance Officer’s uniform — and as a station commander/senior paramedic had an impressive set of pips on his epaulettes. Our coppers were fascinated with him and proceeded to show him the patient’s works set and other evidence to look for. It was all quite interesting and educational for Lance who asked a number of astute questions.

In the meantime, after two to three minutes of ventilating our patient, all the while accompanied by the rhythmic screams of his wife in the background, Vicki started hot-shotting Narcan directly into our patient’s right anticubital vein. We gave all 8 mgs we had in our response bag. Spaced out one after the other waiting for the patient to recover in-between each injection.

Five minutes later our patient is still unconscious but at least is making some respiratory effort on his own. Man, this was some strong stuff.
Being the driver on this call, I was the one who had to trot back down four flights of stairs to retrieve more Narcan from the ambulance. On my way down I passed the fire crew arriving on scene and trudging up to the stairs.

After grabbing three more Narcans, I headed back into the apartment building and up the stairs. As I ascended, I noticed something was different but I couldn’t figure out what. As I arrived on the 4th floor, doing that hypoxia breathing through clenched teeth, I handed the three Narcan preloads to my bride.

She handed one back and pointed behind me. That is when I figured out what was different. It was quiet.

Well except for the firefighter holding on to the upraised arm of our formally screaming wife who was now unconscious and in a crouched position.

She would have been passed out on the floor except for our firefighter holding her up by the wrist and shaking it saying “Lady. Hey lady. Wake up.”

I walked over and hot-shotted her and fortunately she woke up with only 2 mg of Narcan. It was one of those surrealistic moments where she went from unconsciousness to looking up at me and stating, “I just had a baby.”

Seems our couple had just had their seventh child, the other six already having been taken away over the years by social services, and were celebrating their latest child by sharing a fix. It was just a lot stronger than they were used to.

Both were taken care of by a total of 14 mg of Narcan between the two of them and pleasantly walked down to the ambulance for a ride back to the hospital.

Lance, in the meantime, was ecstatic, in that quiet British Commonwealth style.

“Do you realize I’ve seen more Narcan pushed on this call then I’ve done in my entire career? Usually we just replace it because it has expired or the vial has broken. Thank you.”

Yeah, like we scheduled this call just for him. But then again, we were somewhat blasé because this was typical for us but new for him. It was just another one of dozens of H-OD calls we had and would run during our almost 20 years with the city. The same basic theme but with varying subplots.

Like trying to coach a paramedic intern on the value of ventilating first.

Or put more simply, BLS before ALS. Yes, we know young Jedi medic that you have the silver bullet of Narcan. But let’s treat the patient’s hypoxia first and then see about administering it.

This has proved to be invaluable wisdom for multiple reasons. Like for those poly-drug users who use Cocaine or meth but hate the post-high crash so they snowball or speedball. Inject a combination of cocaine or meth and heroin. The stimulant for the desired rush and the heroin to ease the post high crash.

The problem, sometimes the heroin was too strong and they would OD. Our only clue was the patient’s vital signs. Unconscious, apneic with pinpoint pupils but instead of a weak thready pulse, they would have a booming, bounding pulse and normal to high blood pressure.

These were the patients we would really ventilate well and then rather than blast the entire amp of Narcan in, would tease it in in small doses. Just enough to wake them up, but not enough to wipe out the chemical governor actions of the heroin, leaving us with a straight meth or cocaine patient bouncing off of the walls and ceiling.

Our airway adjunct device of choice for these kinds of calls was always the nasal pharyngeal airway. It accomplished the job and was well tolerated by the patients as they awoke. Frequently pulling out the NPA and staring at it with a puzzled look. More than a time or two a smart ass SF medic or firefighter would made the comment, “Hell of booger dude.”

We drilled this concept into one of our paramedic intern’s head. We were running on his second or third H-OD call early in his internship. Again I was driving and Vicki was attending.

We arrived on scene and fire was already there and ventilating our female patient with their BVM.

Her boyfriend was quite amped up and talking away a mile a minute.

His pupils were dilated big as saucers so I could tell his drug of choice was speed or some other stimulant. Being the good support medic, I culled him out of the scene and took him out into the hallway on the pretext of getting a good patient history on his girlfriend.

Over my shoulder I could see Vicki coaching our intern on getting the NPA ready. Selecting the right size, lubing it up with a water soluble lube and then he had fire stop ventilating the patient.

The boyfriend was proving to be high maintenance so he had most of my attention but I overhead our intern say, “Oh shit. Just keep ventilating her.”

Turns out she was one of those folks that had established her individuality by having a septal nose ring and three additional rings on each side of her nostrils for a total of seven.

This turned out to be a good teaching call because without prompting, our intern went back to manual airway control and ventilating the patient up.

When he administered the Narcan, the patient woke up without a problem or a complaint.

In the meantime her boyfriend was becoming increasingly slow and slurred in his speech and when I rechecked his eyes, they were now pinpoint. I gave him 2 mg Narcan IM in the shoulder and we all walked out to the ambulance for the ride to the hospital.

There were many more H-OD calls. Especially around the Christmas Holidays.

As Vicki put it one Christmas Eve night after we had treated our 4th H-OD.

“There must be dozens of mothers across the nation who sent their son or daughter a check and said “here, buy yourself something nice for Christmas”.

But the one Heroin overdose call that truly stands out in my mind, the one I learned the most from, and the one that I was humbled by occurred in 1992.

By 1992 I had been an EMT and later a paramedic for 19 years. I was more than a little jaded by everything that I had been witness to or participated in. And when it came to Heroin overdoses, I was more than a little callous.

Looking back, I was an arrogant schmuck.

(For those of you not familiar with this highly descriptive Yiddish term, it means a prick. As opposed to another great and equally descriptive Yiddish word, Putz, which means a limp dick. Used in a sentence like, “He’s just a putz.” or “Quit putzing around.”)

My view on Heroin overdoses ran along the lines of the theme song from that 70’s TV show, Baretta. “Don’t do the crime if you can’t do the time.” So I didn’t have a whole lot of sympathy or empathy for our H-OD cases. After all, just like the patient who drinks too much, they had chosen to do this to themselves. They rolled the dice and when I would see them, the dice had obviously come up snake eyes. Literally by the looks of their pupils.

Several times over the previous few months, my partner, Mike Whooley and I had responded to the same Tenderloin apartment for a 69 year old female H-OD. She had no veins to speak of and was skin popping the drug. We would ventilate her up and then administer the Narcan IM which would wake her up and immediately push her into withdrawal symptoms.

Pitiful and uncomfortable to witness, let alone experience. But it wasn’t like I was pushing the Heroin on her. After the third or fourth time I had done this, while we were transporting her to the hospital, I asked her why she was doing this.

After all, the tradeoff with age for youth is wisdom over strength and endurance. And God Dammit! She was old enough to know better.

And that was when I was quietly knocked off of my arrogant high horse. She looked over at me on the squad bench and in-between dry heaves said to the effect.

“Sonny, I don’t shoot that crap to get high. I have cancer of the spinal column. Two years ago the pain was so bad that even Laudanum wasn’t touching it and I was in such constant agony that I was considering jumping off of the Golden Gate Bridge.”

I was now feeling about two inches tall as she continued.

“My granddaughter, who had been the bane of my existence up until then came up to me and said, grandma, let me fix you up. And I was so desperate that I let her shoot me up. And you know what? It was the first time in over two years that I had been pain free. So I don’t take this shit to get high.

I just take it to live.”

“And I can’t help it that this stuff isn’t regulated by the Food and Drug Administration so when a new batch hits town every six weeks or so and is not stepped on enough for my usual dose, it knocks me out and you have to be called. So pardon me and get off your high horse.”

I mumbled an embarrassed “Yes ma’am.” And pondered her words for the rest of the transport. And Mike and I did see her several more times over the years. We adjusted the amount of Narcan we gave her IM, just enough to wake her up but not so much to push her into withdrawal.

Our system also did our own dispatching and maintained a frequent flyer book. After I completed the call, I went to dispatch and entered this patient’s pertinent information and history so if anyone else had to respond to her they would go in with their eyes open and avoid my mistake.

And that lesson came back to me with my opiate induced AMS cowboy. I needed to rouse this fellow enough to breath on his own but not wipe out all of his opiate effects and either push him into withdrawal or slightly better, just put him back into a painful agony.

So after we ventilated him up to a 98 percent oxygen sat, I gave him 0.5 mg Narcan IM in his right shoulder. And within a minute he woke up and was not too unduly uncomfortable for our ride to the hospital.

Lesson learned. Mission accomplished.

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