Needle debris: some thoughts from the ED.

[18 Sep/18 Edit: This post is getting a lot of attention which is great. Comments are welcome, but overtly derogatory or threatening ones will be deleted. Thanks for your respectful discussion.]

Like many places, my medium sized Alberta city has been experiencing a crisis of illegal drug abuse, and a second crisis of outrage over the public risk from drug associated crime, needle debris and other fallout. While frustration and fear for the community and public safety is completely understandable given current conditions, I worry that misinformation and a lack of background understanding is generating a lot of unfocused or misdirected anger towards people and institutions that are either not responsible for or are unable to directly address people’s concerns. There is a lot of blame being placed on organizations trying to address the problem, and while feedback and accountability are important, so is understanding what they are doing and why. With a bit more background perspective, I’m hopeful this public energy could be better directed towards efforts for realistic and workable solutions.

I work as an Emergency department physician in the city, but my views are my own, and I’ve had no direct professional involvement with the safe consumption site or the organization that runs it. While I can’t speak for the program or its management, I can provide a few insights on the nature of the drug crisis as I have seen it. I also can’t tell you what the best solutions may be, except to reassure you they are neither quick nor simple. Perhaps what I say will at least broaden a few perspectives, and stimulate someone to learn more about the roots of the crisis in our community and explore how they can be part of the solution.

Illegal drug abuse and the associated crime, violence, disease and death is not new here. It has been in our city for a very long time. There have been community outreach programs for many years offering clean needles, disease screening and treatment, addictions counselling, and access to nearby detox facilities. It is a hard thing for people to escape and a hard thing for health care providers to treat. The roots of addiction often run deep within communities and families, and are often linked to inter-generational trauma and childhood abuse and abandonment. There are a lot of poor choices being made for sure, but often by people who never had the benefit of someone to teach them how to think about making choices.

Getting out of this addiction requires a community of supports and often complete socioeconomic and cultural life changes. This requires deliberate and repeated choices by the addict to accept help and make these hard changes, often developing an entirely brand new way of thinking. That’s in addition to traditional medical detox. Detox can be an important step, but if you leave a facility and return to an old life with family and friends who are addicted and have little to no resources to change their circumstances, you have a very poor chance of staying clean. There are success stories, but not enough. The purpose of harm reduction is to hopefully keep a person alive and healthy enough through their addiction years that they have the chance to go through this process when they have decided it’s time to change, and can achieve a reasonably healthy life in recovery.

Drugs have always ruined too many lives, but a few years ago the illegal drug market in North America changed. What we call “synthetic opioids” arrived and started killing users in unprecedented numbers. Opioids are powerful pain killers. They are effective but can be dangerous if misused. They are addictive because in addition to numbing physical pain, they can also temporarily release you from emotional pain and distress, and replace it with a sense of comfort and euphoria. Those who have lived lives of pain and disconnection from loved ones are primed for opioid addiction. Additionally, regular use will make you more susceptible to both physical and emotional pain when you stop using them. Too much will sedate you. A little more will slow your breathing and eventually stop it. This is how they kill.

Over-prescription and street diversion of medical opioids is a problem that has been around for a while that the medical community is working to address. However, when the “meth lab” industry learned how to make cheap synthetic opioids the game changed. This is the fentanyl crisis you may have heard of. It is NOT diversion of carefully regulated prescriptions, but the black market distribution of crudely made crystals, liquids or pills containing entirely variable and unknown doses of synthetic fentanyl (or its more potent cousins carfentanil and remifentanil). Because small amounts are so potent, and illegal drug labs are not known for their quality control, drug concentration is variable and dangerously unpredictable. One pill might give you a bit of a buzz. The one next to it might kill you. Distribution of the drug spread quickly because it was cheaper to get than other drugs, and it could be cut into anything else (cocaine, meth, marijuana) to provide a “better buzz,” that would bring customers back more often, and at less cost to the supplier. If they survived of course.

Front line police, paramedics, and emergency staff began to see the effects immediately. Opioid overdoses became common, daily occurrences. When a new batch of drugs hits the streets we see dozens of cases a day for several days, slowly tapering off over a few weeks until the next batch arrives. Administering Naloxone (brand name: Narcan) – a medication that rapidly reverses opioid effects – became the obvious first treatment for almost any suddenly unresponsive patient, and often quickly turned around a life threatening event. During my residency training not many years ago, I hardly saw Narcan used at all. Back then, it was rare to see someone who had managed to consume or inject a life threatening dose of opioids outside of a few inner city hospital centers. Now it is common almost everywhere.

Not only is fentanyl killing regular drug abusers who risk death with each high, but it is a serious risk to more casual drug users. You might not know this, but there are people around you living normal lives, holding good jobs who indulge in the occasional “cocaine party” or similar on the weekend. These people’s bodies are not as accustomed to opioid exposure as those of a drug addict, and a lower dose of fentanyl cut into whatever they think they are taking is often enough to kill them. Despite a few years of this madness, drug abuse continues. In fact, I suspect for whatever reasons, rates of abuse are even higher.

Consider this: right now, nearly every drug addict I and my ED or EMS colleagues treat and pull back from the brink of a self induced death, has at least one – usually several – dead friends and family members, recently killed by the same drugs they are still taking. These people know they are risking their lives every time they indulge. I have discussed it with many of them. To anyone who believes the threat of greater legal consequences for drug use is going to be an effective deterrent, or that this is just the life users have chosen, consider how damaged a mind and disordered a thought process this activity suggests. It’s literally playing Russian roulette with every pill or injection, but they still do it. If a gun to the head won’t “change a druggies mind,” then will a fine, a court date, or a jail cell? The answer is obvious to anyone who works with this population.

Let’s look back to about a year ago- perhaps the height of the opioid crisis so far [EDIT: from my local ED perspective at least]. We did see periods of decreased overdoses, I suspect in large part due to stepped up police enforcement to get the deadly stuff off the streets. We handed out a lot of home administered Naloxone kits- saving a few more lives for a time. Still, when more opioids hit the streets, there were deaths and near deaths in droves. While I was not personally involved, it was during this time of many calls to “do something,” we heard word that the city would be rushing to set up a supervised consumption site (SCS). This was not specifically to distribute clean needles – that is something that was already long in place in our city to prevent transmission of HIV and hepatitis. This was to provide a place where someone was supervising drug consumption that was already happening in order to reduce and respond more quickly to potentially fatal overdoses. It is not a new idea, has worked elsewhere, and ideally comes as just one part of a greater package to treat drug addiction and address the multiple social and economic factors that prevent people from getting and staying clean.

I was not on any planning committees, but my suspicion is that in order to address the alarming death rates, this facility was rushed more than it would have been in less pressing times. I’m certainly led to understand that when opened the facility was immediately overwhelmed by the unexpected level of demand, and since implementation has continued to increase its capacity and hours. Predictably, this site has become somewhat of a destination for drug abusers, many of whom are homeless and do not generally have other places they are welcomed to go. I don’t know if there are more or less users than there were previously, but this centralization effect has certainly made the population more visible. It has also increased the public’s sensitivity to the negative impacts of drug abuse on the community; crime, public drug consumption, and needle and drug paraphernalia debris in particular. These are not new issues, and not caused by the SCS. They are the result of a growing drug abuse crisis, and have become more visible because 1- the crisis has deepened over the last two years, and 2- the SCS has made the issue more visible, and probably shifted more of the problem to a single area where people now know to look for it. Additionally, more public awareness and controversy also means people are more likely to publicize their experiences with drug users and needle debris on social media, and these experiences are more likely to be widely circulated than they would have been in the past.

From my perspective in the ED, I am seeing fewer fatal and near fatal overdoses. I don’t have any stats to share, but many of my colleagues have noticed the same thing. We certainly don’t experience the regular parade of overdoses we used to, including days when we ran out of Naloxone. It’s hard to confidently state cause and effect in these type of phenomena, but I believe the SCS almost certainly is behind much of that decrease.

I am very concerned about the risk to children and the public from contaminated needle debris. No one wants local businesses or tourism to suffer because people feel unsafe in certain parts of their community. Of course I want to let my children play in city parks without worrying about them encountering dirty needles or individuals using drugs nearby. But wishes don’t solve problems, and neither does attacking those who are trying to help. There’s another part to this story that might not be on everyone’s radar right now. I heard about it from a friend who works security at the safe consumption site. The site has contracted a firm to provide 24 hour security for their site, and a certain radius around it. You might assume this is to protect people and property from drug addicts, and you’d be partially right. Their mandate includes watching for crimes (including theft, drug dealing or displaying drugs in public) and either intervening or calling the police depending on circumstances and exact location. The friend I spoke with indicated he spends a surprising amount of time protecting these same people from other members of the community who seem out to cause harm.

[Edit: I have removed details of a few alleged events of violence in the proceeding and following paragraphs, not because I disbelieve the source, but because I have no first hand evidence to share, and the readership of this post has spread far beyond my original expectations. A subsequent report by global news has confirmed with both the police and SCS that violence against facility clients has been a problem. The Global report details some incidents. My intention in sharing these anecdotes in the first place was to bring attention to the fact that violence around the SCC is not only perpetrated by some site users, but also against them by members of the public]

I bring up this less publicized side of crime associated with the safe consumption site mostly to urge caution in the spreading of inflammatory material that demonizes addicts, and stokes anger at the public and non-profit facilities that help them. There may be more people than you think in our community who are easily incited to vigilante violence and will feel more justified to commit it as they hear the outrage and frustration of others.

We are well aware in the health care field that drug abusers tend to be very unpleasant people to deal with. We have all been sworn at, spit on, and assaulted by someone whom we just saved from death, while they were about to storm out and try to reverse the help we just gave them. They can be aggravating, threatening, unthankful, and frustrating to treat, and it’s hard to make a positive difference in their lives. We also know they are still people who are vulnerable and living terrible lives with very few options and opportunities to turn things around.

So yes, I would like to see fewer needles in the community. Yes, I’m concerned about crime rates, and the safety of public spaces in the city. But I know closing the doors of facilities that serve users and hoping the problem will go away is not going to solve the problem. It certainly won’t stop needles from showing up in parks. It is a complex issue, and won’t quickly or easily be resolved. All large cities, and even many smaller deal ones with it. If it is a bigger problem here than in other similar sized cities, then we need to look at the socioeconomic reasons why, and try to address them. We need better addiction treatment facilities, so when someone tells me in the ED that they want to change, I have a workable and accessible program to immediately point them towards. We are opening new detox beds at the hospital in November (EDIT: changed from October with new information]. That’s a good next step, but won’t make a big difference alone. Hopefully there are more solutions coming, and I’d encourage anyone passionate enough about seeing change to get engaged and find out how they can help these changes come to pass. We need to continue good law enforcement to keep drugs off the street. We need to continue educating kids that yes, drugs are still bad – even if there is a trend towards more legalization and less punishment for use and possession, they are still potentially life destroying.

And yes, it’s appropriate to talk about how needles are being distributed to achieve harm reduction while minimizing risk to the community. It’s important to continually re-examine harm reduction programs to make sure we are helping without enabling, and minimizing unintended negative consequences that may arise from these programs. It’s important to talk about neighbourhood solutions in trouble areas and respect local businesses, homes and parks. Accountability on the part of city and organization officials working on the problem should be expected. Making those expectations reasonable requires some education about the problem and thoughtful consideration on the solutions. I hope my musings have been helpful to some. Thanks for reading.

The Craziest Thing

“Oh, you’re an emergency doctor? That must be an interesting job.”

It’s true, it is. And I know what’s coming next.

“So, what’s the craziest thing you’ve ever seen?”

Why is it with the number of times I’ve been asked this question I still don’t know how to answer it? I have never once felt like I was able to give any type of a satisfying answer to it. I understand the question and the curiosity behind it. I work in a fascinating world that few people regularly see into. For a time, every day before work I would ask myself, “What crazy thing am I going to see today?” At the end of the shift, I always had a few good answers. So why is it I never know what to say to you, at the dinner party, the church function, barber shop, games night, or whatever it may be when you ask me?

Yes, I do this job to help people – to listen, test, diagnose, treat, refer, comfort and reassure – as do all of us in the health care field. But it’s true- some parts of my job sometimes seem like a human side show. Drama, tragedy, comedy, pathos, heroism- some days are like seeing a parade of people and events straight out of a Shakespearian play. As many before me have observed, we in the emergency department see people at their worst, and in their most desperate of times. Sometimes, because of that, we also see them or those around them, rise to their best. Some people we see over and over again, and wonder how long they can stay at their own rock bottom.

It’s not like we don’t share our stories with each other. Those of us who spend our days working in this strange place regularly exchange vignettes about some of our recent noteworthy encounters. A rare disease we saw, or a diagnosis we just barely made, and how we did it. A difficult patient, an exceptionally bizarre or unlikely injury, a death we didn’t see coming and couldn’t prevent. A story of a patient we felt inadequate in helping, along with the asked or sometimes just implied question; “would you have done anything different than I did?” Sometimes we just need to share our experience of a crazy shift full of a statistically unlikely number of simultaneous severe medical emergencies- always followed by the legions of less urgent patients and their accusing “I’ve-been-waiting-for-six-hours-to-see-you-so-you-better-not-brush-me-off” eyes. It’s easy to share with one another, because we know what the job is like, and we know what makes one shift stand out from the others. We do it to bond, to commiserate, to teach and to learn from one another. My colleague knows how exciting and difficult it is to catch an early diagnosis of a dissecting aorta in a patient who is still stable enough to fly out and into emergency surgery before it is too late to survive. You, asking me at the dinner party might not think that experience was as cool or crazy as one more guy who accidentally shot himself in the hand with a nail gun. Yawn.

Maybe I don’t know what to tell you because as curious as you may be, you don’t know what I see on a daily basis, and have no idea what is or isn’t normal in the ER anyway. My crazy story is lost on you because you don’t know my world. On the other hand, your fascination with injuries or emergencies that are the bread and butter of my days work is lost on me, because I am too deep in my world to remember that anesthetizing, cleaning and closing a gaping 10 inch knife wound on another person’s forehead is not part of a normal person’s day.

My wife gets asked this question on my behalf too she tells me. Her first reaction is “Do you think he tells me the most crazy thing he’s seen?” Oh, she hears a lot of it, for sure. We have a little routine where she asks me how work was today. I tell her briefly about a few unusual things I saw or did that day (all respecting your confidentiality of course). She listens, shakes her head and says, “you have a crazy job.” She tells me how she often answers the question these days. By explaining that the longer I’ve been working in the ER, the less crazy the things that happen there now seem to me.

I also often wonder what you mean by the “craziest thing” that I’ve seen. If I stop and think, I can remember a lot of people, events and circumstances that qualify as “crazy” in my books, but they are all very different. Are you wondering what the most horrific injury is I’ve ever seen? (often I know you are). Yes I’ve seen limbs amputated, blood spurting to the ceiling, brain where it shouldn’t be, and other things out of a Tarantino movie. Not normally dinner conversation. Maybe you’re asking about the rarest medical condition that I’ve encountered? (I know you never are). Those might mean something to a medical student or another physician, but few else. The most tragic death? Most sudden? Most people I’ve told at once that their father/son/husband was dead in a car accident and the noise they made? Most tumor you can have growing in your abdomen and pelvis before the poop starts leaking out of your skin from a dozen places? Most people my age or younger I’ve seen dying of cancer in one shift? Youngest dead child I’ve seen? The feeling in the ER when we were trying to bring life back into a dying toddler, and got word that a second child under one year old was coming in with a possible cardiac arrest at the same time? Oh yes, that counts as crazy in a department that sees at most a handful of child deaths a year. I know the question is never asked as an insensitive one, nor do I take offense at being asked; we want people to know something about the world we live and work in. Yet when the truly tragic events that we see all too often are fresh in our minds, there is really no other response to this small talk question at a casual social function than a shrug and a, “it’s all a little crazy sometimes.”

Maybe you mean the crazy people. The guy high on cocaine with handcuffs and Taser leads dangling from his chest yelling “Juice me again! Juice me again!” The vivid hallucinatory delusions of the untreated schizophrenic patient who’s yelling at the electrical outlets in the secure psychiatry room, warning the CIA agents on the other side preparing to gas him again that his alien friends are arriving soon. The drug addicted woman unhappy at being discharged making sure to stop by every staff member she sees on the way out to tell them to Eff-off. The homeless man who is so covered in bodily fluids that even a fully gowned and masked and very experienced ER nurse has to come running out of his room gagging several times while trying to get him undressed to get at the maggot ridden wounds on his legs. I won’t lie and say we don’t find amusement at times in the eccentric personalities that cross our path. But it’s a humor that is part of our coping mechanism at dealing with people on the bottom layers of society on such a regular basis who are so hard to meaningfully help. Drug and alcohol addictions, mental health disorders and crushing poverty are singly or in combination some of the primary contributors making people into our “craziest” patients – dangerous at times, entertaining at others, but always in unenviable circumstances. Although we may grin or shake our heads at one another at their words or antics, we will still clean them up, check them out, treat them if possible, and provide access to medical care, counselling or social services. Through the swearing, spitting and resistance they often put up we will make their lives a little better, and try to offer them the resources they will need when they choose to take on the colossal challenge of trying to make a bigger change.

Since the question of craziest thing is usually asked in casual light-hearted conversation, perhaps I should just think of the little things that we regularly laugh at in our jobs. There is always a litany of amusing, unlikely stories or situations that come through our doors. Like the men driving a poultry transport truck who opened the back door to find a very agitated cat among the birds “Attacked by stow-away cat in chicken truck,” the chart read. Or a colleague of mine who told me once about a group of guys unloading a clothes dryer from the back of a pick-up truck, as they had been unable to free their friend who was trapped inside it. The brief triage primary complaint note in itself can sometimes tell a whole story. “Lost sex toy- doesn’t know where,” “Drunk on trampoline at 3AM- leg deformity,” “Cat stepped on eye ball,” “Hit on head with frying pan by wife.”

Or there’s the “I can’t believe they came to the ER” people. The mom who comes in screaming carrying her toddler. He had been playing outside and now had a pinhead sized black spot on his foot. It was dirt. The guy who had been having sore feet at the end of the day ever since buying new shoes. Yes, he admitted after some questions, they were probably just too small for him. “Tight fitting shoes,” I wrote on the diagnosis line on the chart, wondering what the official disease code for that might be.

To be honest, I don’t think I could ever say what the craziest thing I’ve ever seen was, because every week or even day it seems like there is something else that I have never quite seen before. That’s the nature of the job and it’s one of the reasons we love it. It’s bringing order, comprehension and healing to the craziness that keeps us coming back. Maybe we are just adrenaline junkies who get our rush trying to solve the problems caused by other peoples’ poor judgement or misfortune. But there is nothing more satisfying about this job than bringing someone back from the brink of death or serious illness when you know they have a lot of quality time left to live because of the knowledge and skill brought by you and the health care team you work with.

An emergency department is a busy place to work, and literally anything can come through that door. Many people we see are upset about how long they’ve been waiting, but most understand that we are doing the best we can with what we have. It’s the only place you won’t be turned away, but no you can’t make an appointment. “Wow, you guys sure are busy today. Is it always this crazy here?” Most of the time my answer is “yes, it’s often like this.” Sometimes though I’ll admit that no, this has been a particularly crazy day. Crazy day usually means there a lot of people waiting with minor problems (still important, still ER appropriate often, but not urgent), AND we have an unusually high number of urgent “sick” patients. You don’t want an ER doctor to label you as sick. That’s not a man cold or even 2 weeks of diarrhea with mildly failing kidneys due to dehydration. Sick is the ER code for someone with a true emergency in danger of imminent death or significant disability from whatever is happening to them. A handful of especially sick patients can bring the rest of the ER to a grinding halt. They need doctors, nurses, IV’s, medications, lab tests, imaging, consultants, admissions or transfers. This takes time and people, and sometimes the “almost sick” and the walking wounded have to wait longer because of this. We all have stories of crazy days: multiple traumas, simultaneous cardiac arrests, bad drugs at a house party. More often it is just a case of several unrelated bad things happening to different people at the same time.

So with all the crazy things we see, and the number of people streaming through our doors, what does it take to raise an ER doctors eyebrows? For us, I think it’s something that is different or unusual enough from what we usually see to stand out. It’s those stand out events that usually come to mind when I am asked the question, even if I don’t have a quick or meaningful way in which to answer it.

I received an email recently from an ER colleague sent to our working group with the title, “we don’t see this every day.” It was a picture of an empty chart rack at 6:30PM. No patients to see. I looked back through some of my picture collection of notable cases at work. An x-ray of a pitchfork in a knee. A cardiac tracing of a rare, but potentially fatal heart rhythm that I had only ever seen in a text book before- a future sudden death averted only because we recognized it. A child’s nose nearly ripped off, texted to a plastic surgeon to convince him to come in to work late, and many others. There among them, was a picture of our patient tracking board at 3AM on a night shift a few years ago. It was empty. Not a single patient on it. Next to it is a picture of an empty waiting room. I remember that night. We went for 3 hours without a single patient in or arriving to the emergency department. It’s not always busy, but that was very unusual. And I think that just maybe that was the craziest thing I have ever seen in the ER.

First Wilde and Random Thoughts

Wilde and Random Thoughts

So I decided to start a blog. Why? Why not I guess. I missed the boat back when blogging was the territory of nerds and geeks, and then it became the domain of creative moms, crafters and family picture archivers. Now it is apparently as everyday common as tweeting how long it took your morning bacon and eggs to finish their epic colonic transit. Everybody else is doing it has rarely been a good enough reason for me, so there must be more than that.

I have always enjoyed, and had I think, some minor talent at writing. Small stories, longer stories, epic length wedding cards written on paper towel from the church bathroom, and the occasional internet diatrab for or against something that struck me as either important or ridiculous enough that somebody should try to point it out. I think I tend to be a deep thinker in many things, naturally try to consider both sides of a contentious argument, and seek to understand how and why others think differently than me. Whether or not I succeed at it will take a more discerning judge than I. Perhaps I wonder if my deep thoughts and considerations would be of interest to others, or I need to a forum to force myself to explore how deep or shallow they really are. Perhaps I just need a soapbox from time to time from which to shout about how awesome or ridiculous this or that is, and pretend I’m the best person to tell you why. Perhaps I need the occasional boost or drain to my own personal narcissism as the situation may warrant (isn’t that what personal blogs are all about?). Regardless of why, here it is, and checking the date of this post, the number of subsequent posts, and the current date will tell you how well I stuck with it. Potential topics may include but are not limited to: medicine, science, food, travel, religion, family, weird things I saw or thought of today, and so forth.

A little about me if you need or want it. I grew up the oldest in a large Albertan (Canada) family- one with grown kids and now several fistfuls of grandkids and counting. And more importantly, one that still likes and frequently visits one another. I myself am happily married, currently with a boy and two girls in that order, mostly school aged. I am a self-admitted, non-recovering nerd with a star-trek and Tolkienesque-fantasy based childhood, and presently suffer from occasional compulsive hobby reading of books about relativity, quantum physics and string theory (so long as they have a lot more words than equations I can follow some of them). I slogged through many years of post secondary school, but since they wouldn’t pay me to study, and I couldn’t stand the thought of a future writing endless grant applications, I eventually headed to medical school (well that’s not how I put it on my applications). I recently finished my residency training in family medicine with extra emergency medicine training, and now work as a full time emergency doctor, which has turned out to be a good fit. Having just been through the craziness that is a medical education, I am now trying to define just what exactly my hobbies are. I do enjoy hiking, camping and skiing. Certainly reading and writing, nerdy computer and electronic things, and long and complicated board games are in. I am also an active member of the LDS (Mormon) church, as is the rest of my family. I spent two great years in southern France in the late 90’s as a missionary for that church.

Enough about me- stay tuned for more riveting, edge of your seat posts in the future!