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Thursday, March 08, 2012

Is your Preparedness Expiring?

Who should pay to prepare? 

Under the premiss of Homeland Security and preparedness, New York State Bureau of Emergency Medical Services (NYSBEMS) undertook an aggressive initiative to arm EMS providers with  auto-injectors to be used to treat people exposed to certain types of chemical agents. As the expiration dates on these materials begin to come due, NYSBEMS, citing budget constraints, has no plans to replace these auto injectors.

If auto injectors for chemical antidotes were so important three years ago, why aren't they important now? The fact is that having auto injectors on ambulances is not an important component of preparedness now. They never were. And the situation leaves a problem of perception. This situation is the latest example of unrealistic resources being put into play without a sustainable plan under the failed model of Homeland Security. It's an issue of poor planning, of being reactionary -  rushing to do something in the name of Homeland Security, in this case, putting auto injectors on ambulances where they'd most likely never be used by EMS personnel who, by an large, lack the personal protective clothing to operate safely in a chemical environment.

Chances are that public service organizations and public health departments in your state are facing (or will face) budget issues that will force similar decisions. New York is not alone, and New York State Bureau of EMS is not at fault for these items expiring without replacement.
The new post 9/11 era message to emergency response and public health: we're out of money...pay for preparedness yourself or don't do it at all.
This issue goes beyond any single item, it's  and issue of sustainable preparedness. Was it ever realistic to place chemical agent antidote injectors on ambulances in the first place? Probably not. And, now that they're not going to be replaced, gives the impression that this initiative is no longer important or the threat is no longer present.

What we're seeing now is the result of a steady, predictable decline in preparedness funding, planning, and operation. EMS has never received an amount of preparedness dollars commensurate with their function and this de-funding of EMS preparedness will continue to hasten the eventual collapse of  public health.

The term Homeland Security does a disservice as it brings to the public mind an image of guys with guns and scanners at the airport or big shinny fire trucks...leaving public health, healthcare systems, and Emergency Medical Services poorly funded, trained, prepared.

When nothing happens, nothing happens. And nobody wants to pay when nothing happens. 

Monday, March 05, 2012

Bath Salts: stronger than dirt

A new "Ivory Wave" of synthetic drugs



PumpIt!, Ivory Wave, and Bath Salts are just a few of the label names of synthetic drugs that are causing intoxication similar to Ecstasy and methamphetamine. These synthetics are often sold in convenience stores, on line, and in your neighborhood may also be labeled as an enhanced plant food...some printed with the warning "not for human consumption". Few, it seems, are heeding that warning as the Centers for Disease Control (CDC) and National Institute of Health (NIH) are calling attention to the growing numbers of emergency department visits, hospital intensive care admissions, and deaths linked to use of Bath Salts. As a example to their popularity, YouTube hosts hundreds of videos on this topic.

Not unlike other drugs, these materials are being swallowed, snorted, smoked, injected or otherwise consumed by a growing population that crosses age, economic, and social barriers. 

From K2Incenseonline.com
What's in this stuff? 
Common chemical ingredients include:
  • Cathinone - a monoamine alkaloid that is similar to ephedrine and amphetamine. Cathinone  has toxic side effects of anorexia, anxiety, irritability, insomnia, hallucinations and panic attacks. This chemical is also known as Khat and is found in plant food.
  • Mephedrone  - a substance known to produce methamphetamine-like reactions in rats.

Patient presentation
Bath Salts, PumpIt! and similar drugs have been compared to a combination of Ecstacy, cocaine and methamphetamine.  According to both CDC and NIH consumption of these and similar products results in symptoms resembling stimulant overdose. Since these drugs often lack an immediate effect, users  frequently increase their intake resulting in overdose situations with neurological and cardiovascular dysfunction including acute myocardial infarction (AMI). Rhabdomylysis has also been reported.

The major psychiatric componant associated with these materials is a psychosis that can last for days. psychotic symptoms may include:
  • loss of contact with reality
  • false beliefs 
  • hallucinations/delusions
  • disorganized thinking and speech 
Patients testing positive for Bath Salt use often test positive for other substances. Be on the lookout for indications and side effects of polypharmaceutical overdose!
If all that's not good enough, intramuscular injection of Bath Salts is linked to aggressive cellulitis and necrotizing fasciitis or flesh eating soft tissue infections. For more on the link between cellulitis/necrotizing Fasciitis see this report from Z6Mag

Its like methamphetamine, cocaine, and Ecstasy...not exactly. 
Image from Z6Mag
  • Like meth, Bath Salts cause a spike in dopamine levels causing users develop a craving quickly.  "Dopamine burnout" is a factor in the abuse potential.
  • Like Ecstasy, there is an increase in serotonin. With continued use, an eventual inability to react to serotonin develops and is related to increased use and binging. 
  • Like both meth and Ecstasy chronic use increases the risk of personality disorders and AMI
PumpIt! has an added twist. This product contains Methylhexanamine, a chemical created in 1944 as a nasal decongestant/vasoconstrictor. Side effects/toxic effects are similar to caffeine and stimulant overdose and include the discussion above with the added increased risk of hyperpyrexia due to a strong thermogenic properties.

Treatment
Treatment is mainly supportive and based on symptoms. Sedation, benzodiazapine, and anti psychotics may be used (refer to local standards). Because of the risk of polypharmacy use, treatment and recognition may be difficult.

Scope

As reported in Morbidity and Mortality Weekly Report (MMWR), May 2011, and in numerous other publications, the scope and severity of this situation is increasing. According to the MMWR report, in a sampling of 35 patients who reported to a Michagan emergency department had the following findings:
  • symptoms similar to stimulant intoxication
  • 32 patients had neurological symptoms
  • 27 patients had cardiovascular symptoms
  • many tested positive for other drugs
  • Hospital admits were to the ICU, medical floors, and psychiatry 

Operational Considerations
There is an increased risk of multiple patients becoming intoxicated with these substance when used in groups. There may be risk for multi patient events. Be on the lookout for commonalities in patient complaints and presentations.

Further Information
The following links were helpful:
Centers for Disease Control and Prevention (CDC) www.cdc.gov
Morbidity and Mortality Weekly Report http://www.cdc.gov/mmwr/
National Institute of Health (NIH) http://www.nih.gov/
YouTube > search keywords: Bath Salt, Spice, K2, Ivory Wave, PumpIt! Power Drug

Thursday, March 01, 2012

Healthcare Providers Targeted by Violence

Physician Shot in Baltimore Hospital...Reminding us that hospitals are Soft Targets.

A lone gunman entered Johns Hopkins Hospital and became upset over his mothers condition. According to CNN.com, the man pulled out a pistol and shot a doctor. He returned to his mothers room and is believed to have shot her, and then shot himself. Also, according to the original CNN.com article, the hospital gets 80,000 visitors and has at least 80 doors that makes security difficult.

We've talked about Soft Targets many times before. Anyplace that lacks deterrents to an attack and holds value as a target (ie place of critical infrastructure) is a soft target. Hospitals are locations of critical infrastructure.
"It's important to understand that open structures with multiple access/egress points, isolated utility and services corridors and large crowds are potential target hazards for multi-patient, mass casualty events. Remember, we're not just talking terrorism here...gang activity can cause collateral damage as well as structural collapse, fires, panic situations, and of course, intentional events." (Hospitals, Hotels, Malls - Soft Targets December 2, 2008 Mitigation Journal)
 I wrote the above quote almost two years ago in response to an attack in India (see Why hotels are easy terrorist targets in MSNBC.com). The reminder has to be that we continue to have locations of critical infrastructure that are open buildings, lacking any deterrent. That is, they're a soft target. Violence against health care workers has been an issue of growing concern for several years. Most cases of violence in hospitals occur in the emergency department, while other less predicable events can occur on any floor.

The recent shooting of a physician at Johns Hopkins Hospital underscores that unpredictability. According to a follow up article from CNN.com, the shooters mother was paralyzed as a result of recent surgery. It was that bit of bad news that caused the man to shoot the physician, his mother, and himself.


The Johns Hopkins event is only the latest in a growing trend of hospital violence. According to this MSNBC.com article, most physicians do not feel safe in their workplace. The rate of attacks and violence is particularly disturbing in emergency departments as noted by MSNBC.com in Assaults on ER nurses rise as programs cut.


While there are no simple answers to the growing violence problem, there are non-intrusive countermeasures. We spoke with representatives from Net Talon on Mitigation Journal Podcast (listen to MJ# 187 here) talking about active shooter situations and solutions. You can also read my posting Active Shooter Brief in Mitigation Journal Blog, July, 2010.


The bottom line on all this is that we must harden our soft  targets...including hospitals...no matter how difficult the task. As tragic as the Johns Hopkins and other events are, they could be much, much worse.