Divemedic

About three weeks ago, we ran to a local shopping mall for a 17 year old male who was telling us that he thought he was going to die. Our exam found: HR140 RR20 BP 140/96. Pt was agitated, paranoid, and very restless. He was acting like he was on speed.

Upon further questioning, he admitted that a friend had given him something to smoke, but he was not sure what it was, just that the friend had assured him that it was legal, and that it was called “spice.” This was not only a new one on me, but the cops on scene had not heard of it, either. When in doubt, supportive care and transport. Enroute, the teen got a lecture about how stupid it is to take drugs without even bothering to find out what they are. I am sure that, being a teen, I was wasting my breath. He seemed to think that because it was legal, it was safe.

When we got back to the station, google was my friend. I found a few things, and here they are:
It turns out that although the drug is new to this area (according to my friends in the narcotics unit of the police department) it is a nationwide problem that began appearing in Europe in 2004, and North America in 2009.It is a synthetic cannabinoid, with effects similar to hashish or marijuana, but it is much more potent, due to a stronger affinity for the CB1 receptor.

Because the synthetic cannabinoids found in these products are new, they remain legal in many states. Kansas was the first state to pass a law banning sale of the products; similar laws have been proposed in Missouri, Tennessee, and several other states. It is undetectable by standard drug testing and standard tox screens in the ED. It is sold in head shops, convenience stores, and gas stations in my area, and a quick check of a few showed that about half of the local quikie marts had it for sale. Common brand names are K2, Spice, and Gold.

 Several medics that I know have begun telling me of calls they are running involving this drug, and it seems like it is taking off in popularity. I have personally talked to 8 medics who have run on calls involving this drug in the last week or two. Reported symptoms are: pale skin, vomiting, hypertension, paranoia, restlessness, fever, tachycardia, dysrhythmias (including PACs and PJCs), as well as tremors, combativeness, seizures and hallucinations. The problem appears to be increasing nationwide.

The compound most commonly found in these products is JWH-018. Another compound, is an analog of CP-47,497, a cannabinoid developed by Pfizer over 20 years ago. Known as (1-pentyl-3-(1-naphthoyl)indole), or the more proper IUPAC name of Naphthalen-1-yl-(1-pentylindol-3-yl)methanone, JWH-018 is one of over 100 indoles, pyrroles, and indenes synthesized by the Huffman laboratory to develop cannabimimetics, drugs that mimic the effect of cannabinoids such as THC. The primary goal of these studies was to create pharmacological probes to 1) determine the structure-activity relationships of these compounds and 2) tease out the physiological function of subtypes of receptors we have for cannabinoids: the CB1 and CB2 receptors. JWH-018 binds to the psychotropic CB1 receptor with approximately 4 times the potency of the naturally-occurring THC. Unlike THC, which binds with almost equal affinity to CB1 and CB2 receptors, JWH-018 exhibits a 4-fold preference for CB1 receptors.

What does this mean? Well, the CB1 receptor is the primary means by which cannabinoids exert their psychotropic effects. The CB2 receptor, on the other hand, appears to be more involved in pain and inflammation and is therefore a very active area of research for new therapeutics. So while JWH-018 has four-fold greater potency for CB1 receptors than THC in an isolated receptor binding study, how its effect compares to plain-old marijuana depends on other factors such as the relative amount in the product, how stable it is to combustion, how it’s metabolized in the body, among others. Smoking as little as 150mg has been known to cause symptoms such as tachycardia and hypertension.

Another report I found talked about withdrawals. The report describes a 20 yr old man with a little prior experience with hashish, some hallucinogens, minimal alcohol consumption and about 10 cigarettes per day. No other illicit drugs reported, nor detected in blood tests during the clinical care interval. He was smoking “Spice Gold.” Initially 1 g daily, for eight months. Due to decreasing effect, he had rapidly increased the dose to a final value of 3 g daily–split into 3 to 4 doses, with the first dose early in the morning. Owing to the consumption of the substance, he had often recently been listless and had had problems in thinking clearly. During a phase of abstinence owing to shortages in supply, he had developed symptoms in the form of profuse sweating during the day and especially in the night, as well as internal unrest, tremor, palpitation, insomnia, headache, diarrhea, nausea, and vomiting. Additionally he had suddenly felt depressed and desperate. This had lasted for two days and had only abruptly disappeared after taking the drug again. Therefore, he no longer had the courage to discontinue the drug by himself.

I have no idea what we can do to treat this, except supportive care and treating the seizures. Any ideas?

To wrap up our discussion of evacuation drills: We have the 90 minute and 9 hour drills. These assume a situation where we may never see the house again, but there is some time to prepare. The movie Red Dawn is similar to that. They evacuated the school to their first rally point, Dad’s hardware store. Then they activated the 90 minute plan and headed for the mountains. (I had to throw in the obligatory 80s movie reference.)

To begin, we grab our 9 minute stuff. Add to that: 4 cases MREs, 4 boxes mountain house freeze dried, a case of pet food, and our camping box. This box contains a pair of two man tents, propane stoves, propane lamps, and all associated hoses, fittings, and camp cookware/flatware. Cans of ammo and the rest of the guns fill out the equipment. We also bring all of our important paperwork. That is the 90 minute drill.

The 9 hour drill is designed primarily for hurricanes, and is the same as the 90 minute one, except we take the time to board up the house, pick up debris and stuff outside and store it in the garage along with our second vehicle.

I have used the 9 minute version several times when being deployed for disasters and such, and it seems to work well, even though I refine it a bit every time it is used.

This is the next installment in my planning for emergencies series. The nine minute drill is a rapid evacuation, where you need to leave in a hurry and can expect to be gone for 3 to five days. This is good for short to medium warning time threats with medium to high risk, like a neighborhood ordered to evacuate for an approaching fire, a chemical spill, or some other localized emergency.

Planning: We established this plan, where we grab the pets, our emergency kits (below), and we consider also grabbing long guns and ammo. If together, we leave in one vehicle. If not, you text the other that you are headed for (rally point) and go. The other will catch up. Don’t forget to bring your wallet and any extra cash you have. If the power goes out, or it is a banking holiday, you may not be able to access cash or credit cards. I also have a WD external hard drive that has all of the backup files for my computer, and I try to grab that. Our rally points would be a little farther away. Six to 100 miles should do it.

To prepare for this, we had to get an emergency kit together. What I did was to pack emergency kits for everyone. There are tons of opinions on how to do this, and I will just throw out a few thoughts here:

I got pet carriers for our two pets. In each carrier, I put a small nylon bag with a collar, leash, 4 single serving cans of pet food, and 4 half liter bottles of water. A calming aid for pets should also be put in there. This will keep your animal family members calm when needed.

The bags for adults will vary, depending on where you live. For example, a person in Montana needs to worry about sub-zero temperatures, while a person in Florida needs sunscreen. Mine is designed to get me away from the house in a hurry and sustain me for three to five days. I put it in a backpack for easy portability. Here is what I think is a minimum: First Aid, heat and cooking, light, tools, communications, food and water,shelter, and security.

A first aid kit. (Note for you medics: You do NOT need ET tubes and bag valve masks. There is not going to be a need to set up your own EMS agency.) Make sure it does have: Sudafed, Ibuprofen, Immodium (diarrhea can be life threatening), Benadryl, Cough medicine (I like Mucinex, a pill is less likely to leak all over the place) antibiotic ointment (infections are nasty during disasters when health care is hard to come by) some baby wipes, mosquito repellent, sunscreen, Bandaids, medical tape, and small sterile dressings. 4x4s will do. A small container of gold bond powder is a life saver when your feet have been wet for days. Also, a spare pair of comfortable socks, underwear, a hand towel, and a tshirt.

Heat and cooking. Three different ways to make fire. I have waterproof matches in a pill bottle, a lighter, and one of these. Here is one in action.

Light  A flashlight with spare batteries. I got this one. It takes a single AA battery and puts out 200 lumens, but only costs $40. I also threw 4 chem lights in there.

Tools A multitool (like the Leatherman) and a pocketknife are indispensable. So is a compass, and it helps to keep a GPS in the car. I also have good road maps of the entire state of Florida in the car under the seat, as well as AAA maps of Georgia, Alabama, and Mississippi. My pickup truck has a built in 500 watt inverter for charging stuff. There is an inverter under the spare tire that is powered by a cigarette lighter. A pair of gloves to protect your hands.

Communications  I put a cell phone charger for our cell phones inside our vehicles, I put one of these that I bought at a local grocery store for $12 inside my kit, and got a pair of FRS radios that I keep on a charger. The wife and I are going to get a HAM license soon. That will expand our options for radios.

Food and water: I included some energy bars (less likely to melt in the heat than chocolate) oatmeal, granola, or similar bars will do. Four MRE meals, and 8 half liter bottles of water.

Shelter: A space blanket, and a cheap poncho.

Security I put a 20 round box of ammo and an extra mag sealed in a Ziploc bag with a desiccant in our kits. 9mm for her Glock 19 in her kit, .45 ACP for mine. I also put an envelope in each kit that contains $200 (20- one dollar bills, 16- five dollar bills, 6- ten dollar bills, and 2 twenties) and a credit card with a $1000 limit.

Remember that this is an emergency kit, we aren’t trying to reestablish civilization or start a war. We just need a quick way to access supplies for a three to five day emergency. This bag has come inhandy when I had to leave to go somewhere in a hurry. Some stuff gets taken out, and some added, as I use the kit and see what works. For example, I deployed to Mississippi for Hurricane Katrina and discovered the need for Glod Bond. Next post will be about the 90 minute and 9 hour plans.

Once the citizens of a nation lose the ability to effectively defend themselves, dictatorship inevitably follows. History has proven this universal truth again and again.

 So, in the country formerly known as Great Britain guns have been virtually outlawed since 1997. Abuses follow:
Britain bans the free press
Cops in Britain force their way into private hoes to enforce debts
Govt employee Doctors in Britain on house calls inspect homes for compliance with safety and health laws
British right to jury trial is gone

 Ignoring the fact of increasing crime, we should note that the people there are now defenseless against any thing or act the Government decides to do. I have talked about this in the past, and had several British citizens argue that I am wrong.

Let’s see what they say about this:

The UK’s tax collection agency is putting forth a proposal that all employers send employee paychecks to the government, after which the government would deduct what it deems as the appropriate tax and pay the employees by bank transfer.

Once you cannot defend yourself from theft, you leave yourself at the thief’s mercy. It doesn’t matter if that thief is the man robbing you at the ATM, your neighbors robbing you at the polling booth, or a cop with a badge robbing you with regulations. Theft is theft. This is why we have a Second Amendment.

There have been 121 officers killed in the line of duty so far this year.
 57 were killed in vehicle collisions of some sort
12 died from heart attacks
2 died in falls
1 killed by a person with his bare hands
2 drowned
46 were after being shot by people using firearms. Of these:

3 were actually shot in previous years and died from complications in 2010 (1996, 1998, 2009)
16 were killed by people with guns of a type that I could not identify
1 was killed by a man with a shotgun 

17 were killed by people wielding handguns, including
– one in American Samoa, where handgun ownership is already illegal
– one by an illegal alien with an illegally possessed handgun
– two in Puerto Rico, where permits are required to own handguns

– One, Travis Murphy of the Phoenix PD, was listed by ODMP as having been killed by a man with a rifle, but he was actually killed by a Convicted Felon who was armed with a  handgun.
– One was shot by the son of a police chief using his father’s weapon (in addition to the other four below)
– Four of them were killed by other police officers, or by a handgun taken from a police officer by the suspect
– One by an armed security guard during a domestic disturbance involving the guard and his wife

Of the nine killed by people wielding rifles:
1 died in a hunting accident
One was killed by a man with a .30-30
One by a man with an SKS
Two by a man with an AK-47 type rifle (the only case this year that I could confirm involved a weapon that was on the Clinton gun ban list)

In short,
– more cops are killed in traffic accidents than by gunfire
– More cops were killed by other cops’ guns than by so-called assault weapons
– Of the 43 deadly police officer shootings that occurred in 2010, at least ten of them were perpetrated by people who were prohibited from gun ownership already, and therefore more gun control laws would have been useless. It was already illegal for them to have guns, and making it double illegal would have done absolutely nothing.

Source is the Officer Down Memorial Page

In a previous post, I discussed the criteria for refusal competency. We covered the reasons why a paramedic would transport a person who has impaired faculties to the hospital. The question we will explore today is another tricky one: When does a person who is impaired by alcohol or other intoxicants become a patient?

This was brought on by a call I ran recently that put my opinion at odds with the opinion of another medic. In this incident, we had been sent to the scene of a home where the caller had dialed 911 because a man was unconscious in his yard, and then woke up and stole a bicycle. When we arrived, a cop was already there. I asked the cop what the guy’s problem was, and got the answer: “He’s an idiot.”

The subject (note that I did NOT say patient) was standing there talking to various bystanders, and only spoke Spanish (not an uncommon occurrence) but the caller/homeowner was translating. The subject also reeked of booze, denied having ID, and was from Mexico (all pretty common conditions in these parts). He denied having been unconscious, and claimed he was just sleeping. He also said that he did not want to go to the hospital. The translating bystander said that his Spanish seemed normal and unslurred.

A brief huddle ensued, and the following decisions were reached:

– The cop didn’t want to arrest him for petty theft, saying the jail wouldn’t take him since he was drunk, until he had been to the ER for evaluation. He also didn’t want to take him to the ER, because it would be hours before the prisoner would be released from the ER to go to the jail, and the cop had better things to do with is time.

– The medics decided that he was not a ‘refusal’ because in order to be a refusal, people who are drunk cannot refuse. Besides, in order to refuse, you must first be a patient.

– An hour later, another crew found him passed out drunk in the gutter, and transported him. This medic was pissed and wanted to know why we didn’t transport him against his will, seeing as how he was drunk.

So what makes a patient? When does a person with whom you have made contact become a patient?

I claim that a person who either has a medical complaint, or a visible medical problem is a patient.

The other medic states that since alcohol intoxication has a diagnosis code, that all intoxicated people are patients and must be transported, even if they have no other complaint or injury. The medic says that drunk people can possibly step out in front of cars, and he doesn’t want the liability.

I responded by pointing out that male pattern baldness also has a diagnosis code, and unless the intoxicated person is drunk to the point where he cannot stand, is passing out, or has some other problem, he is not a patient. I also point out that people have rights, and I am not going to infringe upon them by forcing a person to the hospital simply because they are drunk.

What say ye? At what point does a person who is drunk become a patient? When do you begin the chain of events that forces a person to go to the hospital against his will?

A lot of bandwidth has been spent trying to define just exactly what the Second Amendment means. We all know the words:

The one Congress passed:

A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

The one passed by the States:

A well regulated militia being necessary to the security of a free State, the right of the People to keep and bear arms shall not be infringed.

The words of this Amendment have been repeatedly debated. One word that is continuously debated and changing is “arms.” The collectivists believe that arms means what the founders had access to: muskets. Many pro-gun people believe that arms means the individual arms of the soldier, and that crew served weapons, artillery, and nuclear weapons do not count. Justice Sotomayor believes that nunchuks are not “arms.”

I believe that arms are – well, arms. That is weapons. All weapons. That includes everything from pocket knives to tanks, artillery, jet fighters, and yes, even nukes. You see, I believe that the Constitution means exactly what it says. It says arms, and it is just as dishonest to redefine the words that were used in drafting it to change it as it is for others to do the same.

If you can redefine “arms” to exclude nukes, then why can’t someone else redefine “militia” to mean the National Guard? Or define free speech to mean only speech within your own home is free? The answer to that is: you can’t.

Now I am not saying that I think people should own nukes. I am saying that the Constitution as written prohibits the Republic from infringing on your preexisting right to bear arms. If you want to add an amendment  that says: “Arms, for the purposes of the Second Amendment to this Constitution, does not include Nuclear Weapons or Biological Weapons” then the problem would be solved, and solved in the way that the founders intended.