The Hospital that I work at is a county hospital, meaning that it is primarily funded by the taxpayers and Medicare/Medicaid. In other words, patients pay if they can, but if they can't, that's ok too. The Hospital served nearly 500,000 patients in 2006 (including 81,000 in the ER). Of these, only about one-third were able to pay with commercial or private insurance, and 12% were unable to pay at all. What this means, at least for the ER, is that many of our clients come from severely underserved populations, including the poor, the homeless, and the addicted. These are the folks for whom our Emergency Medicine services are the only kind of primary care they receive.

An interesting case I saw recently was a 29 y/o female who, due to chronic IV drug use, looked like she was about 15 years older. She presented with massive opened abscesses to both arms, which were extremely painful and draining copious amounts of foul-smelling pus, or "purulent discharge," in medical terms. (To see an early-stage closed abscess, click here. To see a later-stage opened abscess, click here.)

I overheard one of the nurses say that the patient used about 6 grams of heroin daily. (Slight tangent: I'm not sure if I believe this. 6 grams daily is a tremendous amount, even for a seasoned junkie. Currently, the purest heroin can cost over $100 per gram.)

Anyway, this case led me to do a little research on the cause and formation of drug abscesses, which typically result from using dirty needles when shooting up. An infection starts brewing under the skin, creating a pocket of pus. Left untreated, the infection will spread, destroying the surrounding tissue, including the overlying skin. At this point, the abscess has opened. Treatment for small or shallow abscesses includes antibiotics, plus a debridement of the abscess itself followed by daily gauze packings and dressing changes. Treatment for large abscesses, like those of the woman I saw, could be amputation.

In my research on this topic, I came across King County's "Harm Reduction" website. (Incidentally, this page is the first that appears if you Google "drug abscess"). If you are not familiar with this, harm reduction is the theory instead of criminalizing a certain behavior, the general population is better served by providing the resources to make that behavior safer. In drug terms, harm reduction programs generally consist of needle exchanges, distribution of clean supplies like new cotton balls, spoons and alcohol pads, and information about the safest ways to use drugs. Naturally, these programs are strongly criticized, as it can appear that they are supporting or condoning drug use.

My position: neither theory is perfect. The government's War on Drugs is problematic, and has been largely unsuccessful in reducing overall drug use (this is a topic for another day). And while harm reduction programs may make IV drug use safer, I believe that it's not the only solution, and emphasis must also be placed on helping addicts get off drugs.

What do you think?

So I've been doing this EMT job for about two months now, and so far it has been about 90% routine (transporting old folks between nursing homes and hospitals, etc.), 8% exciting (car accidents, major trauma, etc.), and 2% "Oh shit." I'll tell you about the 2% here.

STORY ONE
Nearing the end of our shift, we're dispatched code-red (priority, with lights and sirens) to assist with a possible overdose. Police, fire, and paramedics are already on-scene. In a case like this, the paramedics evaluate the patient and determine how sick he/she is. Sick patients are taken by the Fire Dept. paramedics (advanced life support, or ALS), not-so-sick patients are taken by us, the private ambulance companies (basic life support, or BLS). Let me repeat for emphasis: paramedics, who have much more traning than EMTs, evaluate the patient and determine whether they need ALS or BLS en-route to the hospital. Truly sick patients should not be transported by BLS, because we have neither the training nor the equipment to keep them stable.

We arrive at a private residence and go inside, where we find a bunch of cops and medics circled around a female in her mid-forties, who is ranting and raving at everyone in Russian and broken English. The report we got from the medics was that the woman had emptied 7 bottles' worth of various prescription meds into a Tupperware and started tossing back handfuls of them, washing it all down with swigs of vodka. Nobody knew how many pills she actually took, nor did we know what all of them were, as some of the bottles were labelled in Russian. We did know that one of the meds was amitryptiline, an antidepressant, and this was the one that made the paramedics nervous.

With the help of her Russian-speaking neighbor, we finally convinced her that she needed to go to the hospital. Because she was still shouting at us, the medics were confident enough to let her be transported BLS by us. We loaded her up into our ambulance, and one of the paramedics and myself attempted to get her vital signs before we left. It was while we were doing this that she started getting much more sluggish. It soon became obvious that whatever drugs she had taken were starting to kick in, and I started wondering if maybe she should be taken by the medics instead. By the time we were ready to leave, she had become completely unresponsive. The medics told us to take her anyway.

The entire time we were flying towards the hospital, the patient got worse and worse. She became completely unresponsive even to painful stimuli (grinding a knuckle into the sternum, pinching the earlobe), she lost her gag reflex (tested by touching the back of her mouth with a tongue depressor), her pupils were pinpoint and fixed, and she lost her muscular reflexes (a cool medic trick tested by holding the arm up above the face and dropping it; people with this reflex will not let their arms hit them in the face). Her breathing became labored. She did not vomit, and while this was nice for me, this was bad for her as it meant whatever she had taken stayed inside her body.

Things I was watching out for:
- A slowing of her breathing, or a reduced tidal volume. She would then need me to help her breathe, using a bag-valve-mask setup. This uses a big rubber bulb connected to compressed oxygen that I squeeze to drive oxygen into her lungs through a mask.
- Vomiting, which would require me to suction her airway to reduce the risk of her aspirating (inhaling) the vomit.
- Bradycardia, or a slowing of her heart rate. Not much I can do for this, except for start chest compressions if her heart rate drops below 40 beats per minute.

As it was, we got to the hospital before I had to do any of these things. They ended up intubating her (putting a tube into her trachea and having a machine breathe for her) and doing a gastric lavage (removing her stomach contents and flushing her stomach with many liters of saline).

When we opened the back doors of the ambulance, her friend was there and asked, "Is she dead yet?" Apparently, she's tried this before :)

Story Two soon to come...