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How the Opioid Epidemic is Changing Emergency Care

Contributed by Francis T. Strong

Drug overdoses, mostly from opioids, are killing an average of 142 Americans each day. They are the leading cause of death for adults under 50. Philadelphia is expecting 1,200 overdose deaths this year — almost four times the number killed by firearms. That number is up dramatically from the 907 who died in 2016. The city’s Department of Public Health reports that one in three Philadelphia adults — about 469,000 people — used a prescription opioid in the past year. In Chester County, deaths related to opioid overdoses are up 38 percent for the first half of this year compared with 2016.

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The crisis is affecting both urban and community hospitals alike.

Chester County Hospital (CCH) is taking steps to meet the challenges this crisis presents. For example, it has created emergency kits for the nurses to make Narcan more accessible. And the new Emergency Department (ED) under construction will include two high-level resuscitation rooms that weren’t planned with the current epidemic in mind but would be critical in providing life-saving care for overdose patients.

“We’ll have two dedicated rooms near the ambulance entrance and very accessible to the triage area for patients who need resuscitation and then can be moved when they are stable,” said Darren Girardeau, MSN, director of Emergency Services, Radiology Nursing, and Transport Services at CCH.

And for that stage, CCH now has social workers available almost around the clock to help overdose survivors get the additional support and treatment they need — if they want it. “The social workers stay with us right there in the ED while they work through options with the patients and come up with a plan for them,” said Maureen Kennedy, RN, CEN, clinical manager for Emergency Services at CCH.

Those options can make all the difference in what Jeanmarie Perrone, MD, professor of Emergency Medicine and director of Medical Toxicology at Penn Medicine, calls “treatable moments.”

After a person is saved with naloxone, they often “wake up and they want treatment because they almost died, or they’re with a loved one that’s pushing for them to get their stuff together,” said Zachary Meisel, MD, MPH, MSc, associate professor of Emergency Medicine at the Hospital of the University of Pennsylvania.

Having options for these patients at such times is critical, says Perrone. She has been advocating for medication-assisted treatments, such as Suboxone, an opioid agonist-antagonist, in Penn’s emergency departments and primary care clinics, as well as the appropriate trainings for doctors who would be able to administer them.

“If we are able to start them immediately on an opioid replacement treatment, they can have a chance at feeling what treatment is like, that they can do it, and they won’t have withdrawal symptoms all the time,” Perrone said.

Perrone is also helping Penn Presbyterian Medical Center establish a “Center of Excellence,” which will use state funding for specific space in the hospital for people with opioid addictions, ensuring they stay in treatment, and receive care and support. Chester County Hospital currently refers patients to other agencies and facilities to provide the follow-up treatment necessary to prevent relapsing.

An increase in volume of overdoses and other aspects of the crisis present numerous challenges for Emergency Departments. “We’re experiencing this on a daily basis now,” Girardeau said. “We’re generally seeing one or two drug-related cases a day, and often it’s several patients a day.”

Too often, overdose cases arrive unexpectedly by private vehicle, sometimes at the ED or sometimes at other parts on Chester County Hospital’s campus, even the parking garage. A triage nurse and other personnel assess the situation, remove the unconscious patient from the vehicle, and get them onto a stretcher and inside — fast.

“We move very quickly to get them out of the car, clear a critical care bed, and get them into the Emergency Department for treatment,” Kennedy said. And there can be risks while maneuvering someone out of a dark car, as one nurse learned recently when she was pricked by something that caused a small bleed on her upper arm.

The staff is at a disadvantage when 911 isn’t called for an overdose victim. In an ambulance, EMS personnel have a chance to administer Narcan, perhaps reviving the patient, and notify the ED that they’re en route. But sometimes family or friends fear arrest if they call 911 — though there are no legal repercussions for coming to the aid of someone who is overdosing. Deciding to drive the unconscious person who is already having difficulty breathing or not breathing at all to the hospital only worsens an already life-threatening situation. Girardeau is unequivocal on this point: “If there is an overdose, you need to call 911.”

Care can also be complicated because of the combination of opiates involved, including the pain medication fentanyl or carfentanil, an anesthetic used on elephants.

“That is a huge problem. You never know what you’re dealing with,” said Girardeau. “Is it heroin? Heroin laced with fentanyl? Something else? There are some people who we would give Narcan after Narcan after Narcan, but, because of whatever they have ingested — I’m thinking of carfentanil — sometimes that drug is so powerful that Narcan doesn’t cut it. And those patients, if they need ventilator support, would be admitted to the Critical Care Unit.”

In response to the opioid crisis regionally, Mayor Jim Kenney’s Opioid Task Force, which includes experts from Penn Medicine, has been working on a plan to reduce opioid abuse, dependence, and overdose in Philadelphia. Nationally, President Donald Trump has declared the epidemic a national public health emergency, and last year the Centers for Disease Control and Prevention released “Guidelines for Prescribing Opioids for Chronic Pain” to ensure access to safe and effective chronic pain treatment while also reducing misuse, abuse, or overdoses from these drugs.

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