The liquor stores never closed during quarantine. I thought the designation of liquor stores as “essential” was a recognition that alcohol was a quasi-food product—after all, many grocery and convenience stores sold it. Even if liquor stores closed, alcohol would still be available from these other venues. And maybe deeming liquor stores essential was an example of learning from history—a nod to our astonishing failure with Prohibition. But Benny, the vice-president of my fire company, explained to me that, if liquor stores closed, there was a risk that people living with alcohol use disorder would start going through withdrawal. Alcohol withdrawal is the leading cause for seizures in adults. And patients in delirium tremens face a life-threatening condition that requires hospitalization. So, in order to reduce the risk of over-burdening our health system—already pushed-to-the-limit with COVID-19 patients—with an influx of patients going through alcohol withdrawal, liquor stores were deemed essential.
The status of the police as “essential,” however, was in question. In the midst of quarantine, tallying the losses to the public coffers wrought by economic shutdown, the municipal government of the city abutting the county where I was volunteering as an EMT proposed furloughing its police officers. Although this police department is notorious for its race-based violence and injustice, the furlough proposal was not an outgrowth of the defund movement: it was simply a way to save money.
In context, the proposal had its drawbacks. An entire district of the city’s police had been shuttered by COVID-19 infections rampant among the officers, which was consistent with the city’s high infection rates. It was also a possible consequence of concerns (raised by police officers) about inadequate access to personal protective equipment. During quarantine, the governor had called up the National Guard to support the COVID-19 pandemic response in the city. However much communities condemned their local police force, a local police force may still be preferable to the specter of the military enforcing security in a civilian population.
And the city has its legitimate security enforcement needs. Its reputation as a cesspool of crime has its basis in reality. Gang warfare in the city is such a serious problem that communities organize “ceasefire” days to encourage gangs to take 24 hours free from murder. But the gangs and the violence are a dimension of the city’s opioid problem.
“This city’s always been a heroin town,” my friend Trenchant, a singer-songwriter-guitarist observes. Long before oxycontin and the opioid crisis, the city had made opiates its drug of choice. And opiates in the city bled their way into the county.
Quarantine didn’t stop that bleed. With the best intentions of complying with social distancing guidelines, methadone clinics were dispensing thirty-day supplies to patients. Methadone is normally dispensed as a single dose to patients on a daily basis. But the clinics were trying to save patients—and their healthcare workers—the risk of daily clinic interactions. An unintended consequence of the precautions to safeguard against COVID-19 was the sudden increase in methadone on the street.
Under quarantine during the COVID-19 pandemic, overdoses at home seemed to be increasing.Open-air drug markets are a regular feature of some neighborhoods in the area, but under quarantine the situation became surreal. Morale was down among police officers facing possible furlough. Methadone was flooding into the market. And drug dealers didn’t want to contract COVID-19. They were reported to be dealing openly on the street, wearing face masks and gloves. A friend of mine on the police force told me of drug dealers socially distancing from clients and using hand sanitizer after deals.
Although it seems logical to argue that the drug dealers are as essential as the liquor store workers, the argument doesn’t hold. For the most part, opiate withdrawal—while incredibly uncomfortable—is not potentially fatal. People withdrawing from opioids suffer symptoms like anxiety, vomiting, diarrhea, goosebumps, and dilated eyes. Unlike people withdrawing from alcohol, they are not at risk for seizures or delirium tremens, and they don’t necessarily require hospitalization. By contrast, what’s fatal for people living with opioid use disorder is overdose.
And under quarantine during the COVID-19 pandemic, overdoses at home seemed to be increasing.
*
One of the first cases of this sort that I saw was for a 38-year-old woman. Her family had called 911 because she was having a stroke. Dispatch told us that she was conscious, but not able to talk.
My partner for the night was Yochai. Widely recognized around the station as a genius, Yochai handled all the IT needs of the station in his spare time. He had a full-time job in a government agency, but it demanded so little of his prodigious talent and brainpower that he was able to run a consulting practice on the side, in addition to volunteering as a firefighter and EMT. He had also recently been elected to my fire company’s board. For the first year that I’d been an EMT, I’d ridden the ambulance with Yochai regularly, and he’d been one of my best teachers.
On our way to the call, I asked Yochai what he thought was happening with the patient. Aphasia, the inability to talk, is a sign of stroke. But 38 is extremely young for a stroke. Such young stroke patients typically have a heart defect or a congenital aneurysm or some other underlying condition.
Then dispatch radioed us. The patient had become unconscious, and dispatch was adding another ambulance with a team of paramedics to the call. The situation sounded like it might be life-or-death. If there was an up side, nothing suggested that the patient had COVID-19.
A teenaged boy was standing at the door of the house as we arrived. Wearing my N95 mask, eye goggles, face shield, and gloves, I carried an oxygen tank and my diagnostic bag of basic medical equipment as I followed the adolescent into the house and up the stairs. Yochai was about 30 seconds behind me. He’d grabbed a duffel bag with more medical equipment, including medication, from the back of the ambulance before heading into the house.
The teenager, Freddy, was the patient’s son. He led me to an upstairs bedroom. A muscular, bald man with a beard, George, sat on the bed, cradling the patient, Yvonne, in his arms. George wore shorts and a sleeveless undershirt, while Yvonne wore a short silk robe and her bra and panties. Whatever had happened to Yvonne seems to have interrupted an intimacy.
George called Yvonne’s name desperately, pleading with her to regain consciousness. Yvonne’s eyes were closed, and she was drooling.
“I’ll get suction,” I heard Yochai say.
I placed a pulse oximeter on Yvonne’s finger and took her temperature. She didn’t have a fever. The pulse oximeter reading was 52 percent.
A normal pulse oximeter reading is 95 percent or higher. A pulse oximeter reading below 85 percent indicates that the person is severely hypoxic, which means that not enough oxygen is reaching organs, most importantly, the brain. The human brain can only go a few minutes (three to six minutes is the generally accepted range) without oxygen before permanent brain damage can result. Once a person’s pulse oximeter reading is in the 70s, intubation is generally indicated. With Yvonne’s pulse oximeter reading of 52, we needed to act immediately to save her brain function, if not her life.
I unzipped the oxygen tank from its case. Yochai returned with the suction machine, and two paramedics followed behind him. I told them her pulse oximeter reading, while I connected my oxygen tank to a bag valve mask that one of the paramedics, Zeke, took. He fit it over Yvonne’s nose and mouth, and he began manually pumping oxygen into her lungs.
Using the bag valve mask poses a risk of aerosolizing COVID-19 viral particles in the patient’s nose and mouth, and we had been cautioned to avoid “bagging” patients unless absolutely necessary. Obviously, in Yvonne’s case, it was necessary. We had attached a HEPA filter to the bag valve mask to reduce, if not eliminate, aerosolization of viral particles, which posed a danger not only to ourselves, but also to Yvonne’s family, who were huddled in the corner of the bedroom.
While Zeke pumped oxygen into Yvonne’s lungs, his partner, Kayla, did an EKG, and Yochai started an IV line in Yvonne’s right arm. I hastened over to the family to interview them. In addition to George and Freddy, Yvonne’s daughter, Michelle were watching fearfully as we cared for Yvonne. George was crying, and Freddy and Michelle looked stricken. I spoke calmly and in a friendly manner, and they seemed grateful for the distraction. They told me that Yvonne worked as the manager of an apartment building. She’d been going to work, but had been wearing a mask, and otherwise had been socially distancing. She hadn’t had any symptoms of cough, shortness of breath, fever, headache, sore throat, or diarrhea in the last two weeks. She had no past medical or surgical history. She never used drugs and drank only two to three drinks of alcohol every few weeks. Because drug use is a sensitive topic, I asked about her history with specific drugs: heroin? Opioids? Cocaine? LSD? Ecstasy? Marijuana? No, no, nothing like that—everyone agreed.
George’s face was stony. He was frightened and disempowered, unable to compel Yvonne to go the hospital for the care she needed.I returned to Yvonne. Zeke was still pumping oxygen into her lungs; Kayla was reading the EKG; and Yochai was completing insertion of the IV. Now I picked up a lancet and glucometer and took a blood sugar reading from a drop of blood that I extracted from Yvonne’s toe. When a patient is unconscious, we have to consider the usual reasons: heart attack, stroke, low blood sugar, drug overdose. Yvonne’s EKG showed little more than that her heart rate was fast. Her blood pressure was high, but not within range to cause a stroke. Her blood sugar was normal. So we were down to one possibility.
I took a container of naloxone from the medicine box in our duffel bag. Naloxone is the antidote to opioids. I handed the naloxone to Kayla. She inserted it into the IV and pushed the naloxone into the Yvonne’s veins.
Yvonne sat up, eyes wide.
I am sure my eyes were wide, too. The experience of seeing a fellow human instantaneously transported from a place of unreachable, unbreathing unconsciousness—as close to death as is possible—to a state of total awareness and presence is genuinely awesome. Even though I’ve learned the science behind naloxone’s astounding power, every time I see it work feels like being in the presence of a miracle.
“Hi Yvonne, what happened?” Zeke asked.
“I fell asleep,” Yvonne answered, looking around at the emergency responders surrounding her bed.
“I don’t think so,” Zeke said. “You stopped breathing. I had to breathe for you. I was pumping oxygen into your lungs. So it’s important for you to let us take you to the hospital now.”
“I’m fine,” Yvonne snapped.
“You’re not fine, you almost died!” George screamed.
“I’m fine!” Yvonne shouted back.
“We had to give you naloxone,” Zeke told her. “It only lasts two hours, and the opioids in your system last at least eight. So you need to let us take you to the hospital. Once the naloxone wears off, you’re going to stop breathing again.”
Yvonne shook her head. “I’m fine.”
“Mommy, please go to the hospital,” Freddy begged.
“Listen to them!” George boomed. “You weren’t breathing! It could happen again!”
“I’m fine!” Yvonne insisted.
George and Freddy yelled their objections simultaneously, but they were overpowered by a new voice: “I’m a recovering addict, Yvonne, you can’t fool me!”
I turned around to look at the thin man with a black bandana pulled over his nose and mouth standing at the top of the stairs. Michelle stood behind him, peeking over his shoulder. “Michelle just came to get me, Yvonne. You have a problem,” he pronounced with authority.
“I’m fine, Derek,” Yvonne dismissed him.
“You’re going to the hospital,” Derek ordered her. “You almost died, and here you are lying to yourself. You’re an addict, and you’re lying to everyone—lying to your children and the man who loves you.”
Derek seemed to be making a persuasive case to Michelle, Freddy, George—to everyone except Yvonne. “I’m fine,” she said, pursing her lips.
“Maybe family can go downstairs and let us talk to her?” Yochai suggested. George, Michelle, and Freddy seemed relieved by this suggestion. The stress of arguing with Yvonne looked to be as bad, or maybe worse, than the stress of watching her overdosing. Derek and the family retreated.
“Let me explain the way the drugs work inside your body,” Yochai offered. “Your cells in your brain have these receptors that bind to the opioids, and that causes you to stop breathing. The naloxone binds to the same receptors that the opioids use. So as long as the naloxone is bound to your cell receptors, you’ll keep breathing. But after a couple of hours, the naloxone wears off, and those opioids are still there in your body. The opioids bind right back, and you’ll stop breathing again.”
“I didn’t take opioids.”
“What did you take?” Kayla asked.
“I had a headache. I took three pills for my headache,” Yvonne said.
“What kind of pills?” Kayla inquired.
“I don’t know. Headache pills.”
I crouched down by where she was sitting on the bed. “Yvonne, there’s no shame in going to the hospital. This isn’t about judgment or punishment. This is just about your health. We want to do everything that can be done to keep you as healthy as possible, and that means taking you to the hospital so you’ll have the care you need until the headache pills are out of your system. There’s no legal risk—no one’s going to arrest you at the hospital. The only risk is staying home and refusing care.”
“Thank you,” Yvonne said. “I’m fine.”
Zeke radioed a nearby hospital to have a doctor speak over the radio with Yvonne: “You could suffer permanent brain damage or die if you stay at home,” the doctor explained.
Yvonne told him that she was fine. She reminded me of Pierre, the boy in the Maurice Sendak book who always said, “I don’t care,” until he was eaten by a lion—and then disgorged, fantastically just fine. Like Pierre, Yvonne had essentially told George and her children, Freddy and Michelle, that she didn’t care that they feared for her life and wanted her to go to the hospital. She’d told Derek that she didn’t care that he saw through her denial. She’d told me that she didn’t care about receiving the best care possible, and she’d told the doctor that she didn’t care if she was risking brain damage and her life. But Pierre had started to care after his life was saved. Yvonne, for reasons that I imagine are very painful for her to endure, wasn’t able to do that.
Patients—even patients who have just overdosed—are allowed to refuse care as long as they are alert and know their name, the date, where they are, and the situation. Yvonne had capacity to refuse to go to the hospital. Other than attempting to persuade Yvonne to go, and consulting with a doctor over the radio, as we’d done, there was nothing to do but accept Yvonne’s refusal. The right to refuse care is fundamental to a patient’s autonomy. Zeke showed Yvonne where to sign on the refusal form.
I picked up the duffel bag and hoisted it around my shoulder. I also grabbed my diagnostic bag and oxygen tank that we’d brought into the house, and I carried them all down stairs. I encountered George at the landing. He looked wrecked.
“Is she going?” he asked me.
“No.”
He shook his head and walked past me up the stairs.
Freddy and Michelle were waiting for me in the front room of the house. “I think it’s drugs,” Michelle told me. “Mom sometimes leaves the house, and won’t tell me where she’s going. I can’t come with her, and she won’t get me a soda or anything.”
“I had some oxycontin left over from a surgery,” Freddy said, his voice choked with emotion. “There are some missing.”
“This is not your fault,” I assured him. I looked over at Michelle. “You’re in a very difficult, painful situation. I can see how much you love your mom. That love is going to help all of you get through this.”
As I carried the medical equipment back to the ambulance, I remembered how sure the family was that Yvonne didn’t use drugs. Naloxone does not have any effect other than reversal of opioid intoxication. It does not reverse any other drug intoxication, and it does not itself cause a high. There seemed to be little question that Yvonne had taken opioids, and from what Michelle had said, it seemed probable that Yvonne had taken opioids before. But she’d done so discreetly, and no one had had any inkling.
Quarantining during the COVID-19 pandemic seemed to have caused a change in her pattern of using. Maybe she’d taken something stronger than she regularly took. Maybe she’d taken more because of the stress. Maybe she was using alone when she regularly used with others. Maybe she had a false sense of safety using at home. In all events, she’d overdosed at home for the first time, and now her family knew what she’d previously kept secret. The reality that Yvonne and her family had enjoyed just an hour earlier had evaporated.
We have naloxone on the ambulance that we leave with patients who have overdosed. We showed Freddy, Michelle, and George how to use it: it’s a simple device that fits into the nostril and releases a spray with the push of a button. We told them that if Yvonne stopped breathing again, they should first use the naloxone and then call 911.
George’s face was stony. He was frightened and disempowered, unable to compel Yvonne to go the hospital for the care she needed. Freddy and Michelle looked like dutiful children, willing to do anything their mom needed, no matter how challenging it was for them—willing even to take the blame. I was devastated by the unfairness of the situation in which we were. leaving them. But we were helpless to do anything else.
Back in the cab of the ambulance, returning to the station, I thought about the state of anticipation in which we’d left our patient and her family: George, Freddy, and Michelle, at home with Yvonne, knowing that she might stop breathing again tonight, waiting for the worst to happen. The scenario was horrifying.
