Street OxyContin

Last week I was sent to a park downtown on the report of an overdose.  We found a mid-twenties year-old male who was pale, diaphoretic, and tremulous lying in a fetal position, loudly crying.  The firefighters, who were on scene before us, were working him up as an overdose. 

Like the Men In Black, I hate doing my job in view of the public (for them it is “discharge their weapons in view of the public” but close enough) so after getting the basic picture my partner and I got the dude on the bed and moved into the ambulance.

Over the course of the initial exam and history, we found out that the patient was a methadone patient, with a 10+ year history of opiate use and dependence.  That day he had decided to take a leap off the sobriety wagon.  He went to the seedy downtown park and found a nice gentleman with OxyContin to sell.  He bought a tablet of 50-milligram controlled-release Oxy for the bargain price of $20.  At least, he said it was a bargain price – I have to take his word for it.  I thought it sounded weird.  Fifty milligrams sounded like a big dose of Oxy.  Especially for twenty bucks.  But what do I know.

Anyway, he took the pill and found a nice, shady tree under which he planned on enjoying his first non-methadone high in a long time.  Instead of riding a sweet opiate high, he developed nausea, abdominal cramping, sweats, and shakes.  You just gotta hate bad Oxy.

When I asked him what the pill he bought looked like, I was surprised that he could accurately describe it.  He had paid attention, because he wanted to make sure he was getting the right stuff.  It was a round yellow pill with 50/902 on one of the sides.  His salesman, who should be a millionaire with sales skills like this, said that the 50 obviously meant that it was 50 milligrams.  And the 902 was the FDA code for Oxy.  Doesn’t everyone know the FDA code for OxyContin?  The stones on that guy.  Awesome. 

I really hope he looked all "salesman-ish" like this... Source (CC BY-NC-SA 2.0)

I pulled out my phone and typed “pill round yellow 50 902” into the search bar.  Try it and see what you get.  I will wait.

The top hit shows the pills he described.  Naltrexone. 

For those of you who could use some work on medication knowledge, naltrexone is an opioid antagonist like naloxone.  Narcan is more for acute, emergency use and naltrexone is used for more ongoing, chronic management of opioid (and alcohol) dependence.  Both can cause immediate withdrawals in opioid-dependent people.  I love it when a bunch of information all clicks together.  It all made sense.  My patient had to sweat, cramp, and otherwise withdraw his way to the hospital while I sympathetically explained the meaning of caveat emptor and tried not to giggle.  He had the first step of buying something from a stranger – look at the product – he was just so excited about getting high that he never went to the second step - checking for himself what 50/902 meant. 

So there is a dude in the park who sold naltrexone to a junkie wanting OxyContin for twenty bucks.  Classic.

Handoff Reports, Part 2 - Location, Location, Location

Almost exactly a year ago, I wrote up a post about giving a verbal handoff report in a “big room.”  A couple of calls from this week got me to thinking about handoff reports again.  Specifically, I was thinking about the location where I give a handoff report to the receiving nurse.

The first call out of the chute, first thing in the morning, so early it was before I even got a cup of coffee, was a leftover night call that needed to be transported.  When we got the patient to the hospital, we moved her to the bed, got her settled, and I asked the nurse to go out into the hallway for the report.

“Sally, there, is 36 years old.  She absolutely swears that she is only high on life and is positive that she isn’t high on meth.  Looking at her tweaking* and scratching the imaginary bugs off her arms, I am unsure how true that claim is - but I will leave you to come to your own conclusion.  No meds, history, or allergies.  BP one-forty over ninety and a pulse of one-ten.  Anything else I can do for you?”

The next call was to a clinic to transport a hypertensive patient to the hospital.  When we got to the hospital, I put the ambulance pram next to the hospital bed and asked the patient to move himself over.  I stood behind him, at the head of the bed, and waved to the nurse.  When I got her attention, I silently made the “watch this” sign by pointing at both of my eyes and then pointed at the patient.  The patient moved to the hospital bed using both arms to lift his weight and swinging his butt from one bed to the other.  The admissions clerk asked to see his ID, and the patient fished it out of his left front pocket and I asked the nurse to step out into the hall for the report.

“Jimmy, there, is math-years-old from 1962 and went to the clinic to get a lisinopril script filled.  He ran out two days ago and needed some more.  The clinic found his pressure to be pretty high, with left arm weakness and blurry left vision, so they called me.  When formally tested, like with the Cincinnati tests and all, he does indeed have left arm drift.  You saw his arm strength, though, when he moved from bed to bed.  Plus he dug his wallet out of his pocket pretty easily with his left hand.  So the clinic doc had some questions about how much of this is a factitious thing, and I see his point.  But on the other hand, he does have a BP of two-twenty over one-thirty, so there is that.  That’s not factitious.  Heart rate of eighty-eight, sinus without ST or T changes or ectopy.  Along with the lisinopril he hasn’t been taking, there is Keppra that he has been taking.  Anything else I can answer for you?”

The last patient of the day was under arrest.  After moving the patient from pram to bed, I asked the nurse (and doctor, this time) to step out into the hall for the report.  “Seventeen year old male, was supposedly seen by the cops selling drugs.  There was a short foot chase and the cops say that he swallowed a bunch of baggies while running.  The end of the chase seems to have been about as gentle as a chase can be ended – the cops say they didn't whoop him and he says he wasn’t hurt.  He denies selling or swallowing anything, and was refusing all treatment.  He is under arrest, though, with a pressure of 130 palpated and a heart rate that went from one-thirty right after the chase down to the nineties now.  Secondary exam is all normal and he denies meds, history, and allergies.”

Several other calls went without issue that day.  Patients were treated and handoff reports given.  All the other reports that I gave that day – a dude who was trying to figure out why his can of bug killer wasn’t working so he accidentally sprayed it into his eyes, a non-specific vague chest discomfort patient, a guy with pancreatitis who had a belly ache, and a couple of car crash victims with minor pain complaints – all heard my handoff report.  One of the car crash patients disagreed with my description of her dust-transfer accident as "minor."  That’s fine – patients can correct anything I have wrong with the nurse after I am done, and I tell them so.  But I started thinking about why I decided to give some handoffs inside the hospital room and others outside the patient’s presence. Why did I give three reports outside of the patient's presence?

Maybe I think too much about the details of my job. 

I considered how I would feel if the paramedics dropped me off and then whispered out in the hall with the nurse, glancing at me over their shoulders, gesturing, and laughing.  Even if the medic and nurse were laughing about something completely separate from me and my case, how would I know that?  Which got me to thinking about when it is appropriate to give a “secret” report.  I mean, the meth chick knew I thought she took meth.  That wasn’t a secret.  She knew she was under arrest.  The hypertensive guy could have heard what I thought and corrected anything I had wrong.  I misunderstand things all the time.  The arrested kid knew he was arrested and knew that the cops accused him of swallowing little tiny baggies.  Nothing here was secret.  Why did I move out into the hall for those reports?

It reminded me of when I was in the hospital for a night after an appendectomy a few years ago.  In the morning after my surgery, my surgeon and a load of residents and interns came into my room for rounds.  One of the residents (probably the one who actually did the surgery) gave the group a report.  Questions were asked and answered.  Several of them took turns examining my belly.  It wasn’t insulting or frightening.  It was nice to hear their thoughts and the plan for my discharge.

I decided that I need to move to the hall less often when giving reports.  Patients deserve to hear the handoff report that involves them.  I am sure there should be exceptions.  Each decision needs to be evaluated for costs and benefits.  That is true for everything from medication administration to handoff location.  But for the most part, I have decided to talk about patients right in front of them whenever possible.  I can’t think of a whole lot of cases in which my handoff should be secret from the involved patient. 

Can you?  What are some examples of cases in which the patient shouldn’t hear the details of their handoff report?

*As an aside, is there a medical term for “tweaking”?  You know, shakes and tremors with the constant need for movement, but trying to hide it – resulting in the stereotypical meth dance tweakiness.  What is the medical description for that?

Judicial Agents

Last week I was at the airport and was called to a sick case.  At the airport, I work alone (no partner) from a golf cart or Suburban, which makes calls fun and interesting.  But it also makes in-call collaboration much more difficult.

I found a 20-year-old female sitting on the uncomfortable seats that airports provide.  She was sitting with her hands behind her back and her head tilted back.  She was conscious, but pale and very diaphoretic.  The patient had been walking from the car to the terminal when she felt lightheaded, fainted, and was helped to the ground.  She still felt presyncopal, so I tried to move her to the floor where she could lie down.  Unknown to me, this was apparently a hassle.  You see, she was a prisoner being transported by two other people.  Those two other individuals were not willing to take her handcuffs off.  They showed me badges with the title “Judicial Agent,” as though that should clear up all my handcuff-related questions.

What the hell is a judicial agent?

(At this point, my temper was starting to rise a little.  It is a pet peeve of mine when someone shows me a badge.  Badges can kiss my ass.  Anyone can pay to get a badge stamped.  I want to see credentials.  Apparently, credentials were a hassle for the “judicial agents.”  Good.)

Let me jump around a little to tell the story.  Apparently, my patient was under arrest being extradited to another state by the two judicial agents.  They were not U.S. Marshals, sheriff deputies, or anything like that.  They were "judicial agents" and they had a ton of paperwork that might or might not have shown that they weren’t nefarious kidnappers.  It looked like a living will, where there is 30+ pages of stuff I don't care about, but somewhere in there is the one line that answers my question.  I didn’t have time for the paperwork, so I called for some police assistance; maybe police officers have seen warrants and extradition paperwork before and knew what to look for.  I sure didn’t know.

The patient had no medical history (that she would tell me about) and took no medications.  She had never had fainting spells before.  I eventually got her laid down and got a blood pressure of 70/40 and heart rate of 110.  Sinus tach without changes or ectopy on the TV.  The physical exam was normal, outside of the pallor and diaphoresis (both of which were starting to ease up).  She was fully down with going to the hospital and was appropriately concerned that she didn’t feel well.

What needs to be done?

That’s right – she needs to go to the hospital.  So I called for a transport ambulance, an action that was met with resistance when overheard by the judicial agents: “What? Oh, no.  She ain’t going to the hospital.  No.  She is getting on the airplane and going to [unnamed state] with us.”

At this point I had a problem that I have never run into in 20 years of EMS.  See, when people are under arrest, they can’t refuse transport.  A law enforcement officer gets to decide where your body is physically located when you are in his or her custody.  If the law chooses that your arrested body is located in jail, you go to jail.  No refusal is allowed – try telling the cop cuffing you that you have decision making capacity and would like to refuse his arrest.  If the officer wants your body to be at a different jail, off you go from the first jail to the second one.  If the law enforcement officer chooses to locate your body at a hospital, off you go.  Arrested people with decision making capacity can still refuse procedures – they can refuse medical treatments performed on their bodies when they have decision making capacity – but they cannot refuse where their body goes.  Does that make sense?

But what happens when the “cop” says the sick body that needs hospital attention cannot go to the hospital?  Would forcing transport against the stated will of the officer be the equivalent of aiding escape?  Could I get into legal trouble, as though I had helped in a jailbreak? 

That’s what had never happened to me in my career.  I have never had a cop deny transport when I said it was needed, especially in a patient that was visibly ill-appearing.

I still don’t know the answers to the questions.  The police officer that showed up on my scene to help answer such questions had a badge number from the age of disco and a revolver.  He was grandly and exuberantly uninterested in rendering an opinion other than shrugs indicating inscrutable apathy.  So if you are looking for education from this week’s blog post you are going to be disappointed.  I never have really definitively found out what a “judicial agent” is and what their powers are, either.  Apparently, sometimes it can be a fancy name for a bounty hunter.  But these “agents” didn’t have mullets, tattoos, excessive jewelry, leather vests, or fire extinguisher-sized cans of OC.  I didn’t get a bounty hunter vibe.  Sometimes “judicial agents” are investigators for district attorneys, judges, or judicial districts.  These people were probably along that line of work.  They looked like professionals.  But what rights and responsibilities go along with that?  I didn’t know and still don’t. 

Of course, this is how I picture all bounty hunters. Source

So on this call, I utilized my only weapon: Being a pain in everyone’s ass.  After several minutes of that irritating course of action, one of the “agents” got fed up and stepped away to get on the phone.  After a few more minutes, he came back and uncuffed the patient.  The warrant was cancelled and the patient was free to go.  Apparently his boss felt the patient was a serious-enough offender to require paying for multiple airline tickets and hotel stays, but not serious-enough to pay for an ED trip via ambulance.  [Unnamed state's] tax dollars at work.  The patient got into the ambulance for her trip to the hospital, the “agents” got into the TSA security line to catch their flight, the police officer wandered away, and I returned to service.

Weird call, I told you.

My best guess was that the patient got herself busted and missed a few doses of something that she was unwilling to admit to me.  Maybe she was withdrawing a little.  I don’t know what happened to her in the end.  I'm just glad I didn't have to facilitate a jailbreak in order to get a patient the care that she needed.