Stephen Murray MPH, NRP - Caring for People Who Use Drugs (10/18/22)

Say Paul. Say it again so I don't have to look at my. My text.

All right. 1 5, 3. 1531 5. 15315 or 15? 3 15.

And what about Eagles today?

That's 16.

1 3. Sorry. 1531 6.

Yeah. This is so funny. I just sank in the chair here, so.

Okay.

But you could see me. Okay, right?

Yeah, yeah. You're looking handsome with a jacket today. Wow, look at you.

Oh, yeah, I was. I'm actually in. Can you guess where I am today?

Yeah, you look like you're in a city commissioner's office in Dallas.

Yes, exactly right. That's where I was seeing all the commissioners, all that we. They were happy that I had won some award or something. So they were talking about it. So caught up with the health commissioner as well. The health commissioner as well for the county and had a good day so far. So.

Well, before we start.

What.

What award was it? You want to let us know?

Oh, they were just congratulation on the. The best paper recognition that we got at ASAP last week, you know, that's all.

Oh, the heads up cpr.

Yeah. Yeah. Cause it was out. Came out in Medscape. So somebody saw it and they. Whatever wanted to. Since it said Dallas county, they wanted to sort of recognize that.

That's all very nice. Well, congratulations. Congratulations on that.

Okay.

Okay, so let's get started. I know we are recording, so just. Stephen, so you know that we are recording today. This is a. A very important topic that I think, you know, I'm fortunate that in the EMS community we have people who are doing great work, and when you ask them to come present, they tend to say yes. And today's guest is no different.

So Stephen Murray is from the Boston area. He's got a master's in public health. He's a paramedic. Your rank, Stephen, is one of. Lieutenant Chief. What are you.

I was a lieutenant before I retired, yeah.

Okay.

Department.

Were you in northern Berkshire? Ems. So in western Massachusetts we're a regional agency?

No. Well, I have friends in Greenfield.

Okay. I actually. I went to paramedic school in Greenfield, so.

Okay.

You know the place that used to be Old Town Library? It's now kind of a museum of sorts for.

Let'S say, keyboard instruments here. I will talk later, but it's kind of fun. I'll tell you more about it later.

Did I hear you were in Dallas as well?

I am in Dallas today, yes.

We probably. Probably crossed paths. I just got back yesterday. I was at the conference as well.

At the police conference, was it? Or.

Yeah, yeah, I presented. I presented on Sunday.

Ah, okay. Got it. Well, thank you so much then, for your support and help. Okay. Really appreciate that.

Excellent, Stephen. Thank you so much. So Stephen is a researcher and the title of his recently published paper, which caught my eye, was Caring for People who Use Drugs Best Practices for EMS Providers. And I just came out of a chiefs meeting here in my department and we were talking about how really in EMS now and into the future we're going to see a lot of mental health issues and a lot of addiction issues. So unless we kind of refocus on how we think about this, we're going to be in a lot of trouble. And so this is a perfect time, Stephen, for you to talk about your paper and your thoughts. So we're going to give you the microphone and take it away. Thanks for joining us.

Sure, thanks. I'm going to actually share my screen.

I need to be. You guys see that? Okay.

Yep, perfect.

I need to keep myself on track. So I do use PowerPoint. So thanks for the introduction and for inviting me.

This is a good forum for this. I haven't actually gotten the chance to speak to many EMS groups yet about this project in this paper. So you guys are kind of a pilot for me. So thanks for inviting me. As was said earlier, I work for Boston Medical Center. I'm an overdose researcher. I'm also an overdose survivor and person long term recovery. I've been recovery for 11 years for both opiates and amphetamines. And I wanted to give you guys my Florida connection, since we're in Florida today.

Florida is where I was using drugs. So I was a student at the University of Miami back from 2007 until 2011. That's me pretending to graduate in 2011. I actually was handed an empty diploma like everybody else on that day, except I wasn't actually finished. I was far behind. I had fallen into pretty deep addiction. A couple months later, I ended up in rehab. And when I was in early recovery, I was looking for something to do and I had no idea what I was going to do with my life at that point. And so I became a volunteer firefighter. And that was actually my pathway towards a healthy recovery. And eventually went on to become an EMT and then a paramedic and served almost a decade in western Massachusetts.

So that's sort of my background. So the paper that I wrote is actually about a training that I created as part of my master's in public health. It's a practicum project. And what I did was I took a mix of my personal and professional experience. So personal experience as a person who used drugs and my background in the harm reduction world, I also didn't mention I'm on the Massachusetts Harm Reduction Advisory Council. I work on the Drug Checking Advisory Board for New England and do a lot in the sort of national harm reduction movement. And so I mixed these ideas together and then I mixed in my professional experience because for a lot of my EMS career, the people that I worked with, both pre hospitally and in the hospital, had no idea that I was in recovery. And so I saw a lot of things sort of through an unfiltered lens as to how my colleagues thought and felt about people who use drugs, how they spoke about them when they thought nobody was listening. And that all stopped when I came out. So I'm glad that I waited a while to start talking about it because I actually got to see kind of what was going on and where stigma was. And then also I spent a significant amount of my career working in CQI doing quality improvement and so looking at reports, looking how people had documented what had happened and what they were doing. And so this, this training really.

Really.

Is just an outpouring of that. So the paper that the doctor is referring to is this one. It was published in Health Promotion Practice. They have a section that's called Practice Notes and it's actually for interventions that are not finished and don't have data, where you basically publish a process paper. I can send it to anybody who's interested. Just feel free to send me an email, I can send it along to you.

And this paper really only talks very. It's a brief paper, has to be under a thousand words, and it just talks about the process of developing the training, sort of the assessment of need, the introduction of why I thought this was an important paper or important project to do. And so that was published and had a really good reception, actually, which to me has indicated that this is an area, I think, as was alluded to, where we need to be talking more about this. People are interested in the topic, it got scored in the top 5% of research and it really is just a short paper about a project. So I think that we have a lot of work to do in this space. The way the training is being evaluated is through a post pre survey. So instead of giving someone a survey in the beginning and one at the end, you don't, you only survey once at the end, which is the theory. There's a theory of that if you survey people only at the end, you help to get rid of this idea that people don't know what they don't know. So if you ask somebody how they felt before and they don't actually have a context for it, they're going to try to guess an answer and guess the answer that you want them to hear. Whereas at the end, they may be more open about how they feel now versus how they felt before. And they rate sort of how their knowledge, beliefs, and attitudes change over time. So this is just a sample of the questions. I think there's like 30 something questions. But this is just an example where people would be asked. So if I see someone I work with mistreating a person who used drugs, I will speak up. So a lot of people in the sort of preliminary research would say sort of neutral or disagree. Most of those folks have now moved into the agree or strongly agree category. I plan on starting to do, like a real analysis at 100 evaluations. One of the hard parts is that.

To get people to. People will take the class, but they are able to opt out of doing the survey. It's an IRB requirement by our institution. So I've had quite a few more people take the class than do the survey, but we're getting there about halfway. And we only launched about a month and a half ago, so pretty happy with that so far.

So I'm just going to include two quick examples to sort of show you what the training was about and kind of how it was structured. So what I did was I looked at ways where I saw that things were happening one way that for a certain group of patients and not another way for another group. So my classic example is that for anyone who works in ems, you know that, like, probably our number one medication, at least here in Massachusetts, that we give out is Zofran. And so we give Zofran to everybody. Abdominal pain, you know, they get pain medication, they're nauseous, they get it. I mean, we give it out like candy. They do in the ED as well. But I really rarely saw anyone ever give Zofran to somebody after an overdose. And after an overdose, when you're in withdrawal, one of the main sort of symptoms of early withdrawal and maybe too much Narcan is that they're vomiting. And then so I would ask my medics, who worked under me, why didn't you give Zofran? And they would say, well, I didn't have an IV on them. And so I said, well, you know, we can give Zofran PO or IM as well. And so this kind of, this is a constant theme in this presentation is that one of the main excuses I've heard across the board is that we didn't get an iv, their veins were bad, I missed. And that was sort of justification for not giving pain medication or giving anti nausea medication or whatever. And so in every example that I give on how to sort of improve the level of care, I talk about the alternative routes of administration or alternative medications that could be given in that situation.

This is a case, it's actually a real case. The second slide is going to show you actually how I handled the case. But this is actually something that I saw quite often which was that patients that were potentially paramedic level patients were downgraded to their BLS partner because they were a person who used drugs. So in this case, this person had.

Really bad injection wound on their arm.

They were in severe pain. The medic decided that it wasn't an ALS call and handed it over to the BLS partner. And so what happens to that person? You know, nothing is done on the way to the hospital. When they get there, they end up in the waiting room or in an express room and the patient could just walk away, they could leave without being seen. They feel like they were treated poorly, they may just walk out. And so what does that do? Well, they could have significant delay of treatment or diagnosis of a serious condition. And so in this case, this was an actual case that I had where a young woman had been reusing syringes and it caused significant forearm arm wounds. And so how did I look at that? Well, she actually was in severe pain. So what did I do? Well, I actually couldn't get an IV on her because both of her arms were in bad shape. So I gave her IM, ketamine at 1 milligram, a kilogram. That made her much more comfortable. She said thank you. She stopped screaming. She was in much better shape. And that allowed me to actually then go on to do other stuff with her because now she was comfortable. So once she was comfortable, I was able to then do a full set of vitals. And I found that she was febrile. And so what did that do? That opens up the cascade to start talking about or thinking about, like, is this person septic? She happened to meet all sepsis criteria, basically that we had laid out in the state, which made me work a little bit harder to find an IV access point, which I did, started some saline, I called in a sepsis alert. And so what happens then when that person or that patient gets to the hospital, well, they're going to be treated much differently. They're coming in as a sepsis alert. There's been stuff that has been done. They've had pain management that has been started. And so a physician in my hospital, if you come in with a sepsis alert, the physician will generally meet you at the door to have a discussion. So that patient was seen right away. She ended up in the icu. She did make a full recovery. She was initiated on Suboxone at discharge and she actually has been in recovery for two years. She just had a very healthy baby girl. I was able to go to her baby shower and she's doing really well. And so, you know, this is just a really good feel good case. But this is sort of like the standard of care that I would try to demand of our medics. So that's all. I think I only had 15 minutes. So I'm going to end it here. If you want to check out the training, you can do so at this link. Keep in mind that it is case sensitive, so.

Pu pwud so people who use drugs. EMS22 feel free to reach out to me by email or on Twitter. I'm happy to write back and have a discussion. And I'm going to stop sharing so I can see.

Before you stop sharing, let me. I'm going to type that. Actually, can you put it back up? I'm going to put it up. I'm going to put that into the chat.

Yes.

Only because I know that a lot of us are so. Tinyurl.com pwudems22 right.

Yes.

Did I get it right?

I can't. For some reason I can never see the chat on teams because our institution won't let us have a sign in. And so I actually. So if anyone has written me in the chat, please feel free to unmute yourself so I can see you and we can answer any questions you might have.

Awesome. Well, Steven, obviously you're not only passionate, but I did not know your history with.

Drug use and the fact that you were able to kind of be on the inside hearing what people were saying about people, the person that you were and how it impacted you and you actually said, hey, I'm gonna do something about it, educate the rest of us. So I think there's a lot of power in what you're doing. You're a great speaker and I think that, you know, this is a message that needs to be kind of spoken at every firehouse across this country. I Would love to hear what, what some folks have to say on this call. You have a lot of people here. You have people from, from the state of Florida, you have people from Canada, from the federal government around this call who are listening to you from the state of Florida as well. And is this something that you would say that we could just take that URL and have our folks take it? How long is that training? Can you just give us a little bit more detail on that and then I'll let Dr. Pepe come in.

Sure. It's an hour and it was approved only for Massachusetts OEMs credit. However, if someone from the state of Florida is here and you think that that training matches your protocols without any editing, feel free to issue a Florida. I'm not sure how you guys do your research there, but if you could or if you're able to a Florida OEMS credit. I have been in talks with some other states about adapting it to their state protocols and it's not that big of a deal to do. What I would want to do if places we're interested would be to give it once live and have it recorded and then you can continue to issue it out asynchronously for your state. Instead of like doing what I did, which is like create this whole recorded training which was quite time consuming, I would rather just deliver it live if other states are interested in doing that. So I'm open for that. But if it seems to match your protocols close enough that you're okay with issuing that credit to the folks in your state, I'm also happy for you to do that. And I can actually amend the final certificate if needed. So. Haven't had any states take me up on that offer yet, but you guys are only like the third place I've talked to.

So.

Yeah, no, I think you're getting a lot of traction. Dr. Pepe may have some great insight. Go ahead, Dr. Pepe.

Well, first of all, my reaction at first is that a lot of times we see people when they're really been down and you know, the pictures Ken has shown of some people, for example, and then what they look like when they recovered or if you look at them before they did. So what I'm getting at is that we encounter people probably in their worst situation, number one. Number two, I betcha that everybody on this phone knows someone that's either close to them or pretty close to them that actually had such a problem and, or is having such a problem at this moment in time. And I, I can personally say that through my life, I've had cousins, I've had best friends or, you know, pretty close to being best friends kind of people that got there. Fortunately, in some cases they recovered, in other cases they did not and met their death. And so I think all of us know that. I want to put that in perspective. If you know those kinds of people that were close to you, what they were like before they got addicted.

Keep.

That in mind as you approach someone on the streets. Everybody is a human being and they got there somehow because of some reason and all that. And we're into this to take care of people, C A R E, not manage them or treat them. Okay, how's that?

Great, Paul, thank you so much. You know, the question is, is how do we take somebody with your insight and experience and Steven's history and experience and translate it to our very new green paramedics who quite frankly are different generation. We can all agree with that. They're younger, they don't have that interpersonal skill.

And there's. They, they may kind of go into these situations just like that perfect sepsis case was beautiful. Because, you know, how many things are we missing because we're anchoring on some other diagnosis, Right?

Yeah, exactly. Yeah. Okay, thank you, Peter. That's a great insight. I don't know the answer to that question right away, except there'd be a role model and as best we can.

Well, no, well, so that I would say that if Stephen created a one hour thing that everyone can do and you know, normally things like this take, you know, four hours, eight hours, you gotta all gather into a room. But what I'm wondering is if after someone takes this course, right, or without credit, whatever, that's not the important part at this point for me, but it's how do we then evaluate, did it make a difference? So Stephen, back to you then. Are you, are you actually looking pre and post as far as the actions being taken on medics in X department? You know, let's say before they weren't getting any Zofran and now they're, now that we've doubled the amount of Zofran, like, are you, are you able to look at real world data before and after? I think that would be an interesting thing.

So that would be like a next phase. So with, with stigma training, there's always the risk that what you're doing worsens people's perceptions of the sort of marginalized population. And so my intention was to have this initial, initial training go out, see if it made a difference for people and sort of from my preliminary look, it seems to be doing that. And, and then once I have the sort of basis that this type of training and such works, I would hope to then do it on a scale that you're talking about, which would be to like pick a state or pick a department.

Institute the training and then see what the sort of before and after effect would be.

It would have to probably be a large department to get the kind of the data that we're looking for or like a county wide system or something like that. But I think that's absolutely the next step after if I can prove that this works.

Yeah. Well, I'll tell you what. You know, I'm with Palm Beach County Fire Rescue as well. Big, big agency. We run about 160,000 calls a year. We have about 1500 paramedics and we sure do see a lot of patients who are in that category. And so anyway, I would be interested in.

Floating out some education. We have great data collection ability, so I'd be interested in doing that. I would love to hear from some really smart people on this phone call. Anyone have any other thoughts about, for Stephen as to what could be done or how we in Florida can maybe utilize what he's created? Anybody.

Want to unmute their microphone and give some words of advice?

This is Terry Cohen.

Hey Terry.

You know, it's been my general perception that communication skills are gradually deteriorating over time as people become more and more used to social networking on platforms and people aren't very good at talking face to face anymore. So it's something we really need to focus on.

What Terry said because I think it's so appropriate and often we've learned to be mean spirited that way because you can get away with, you couldn't say it face to face to people or you make, you know, whatever innuendos or whatever that are just unkind, that kind of thing. So, Terry, I absolutely agree with you.

Thanks, Terry. John, you want to say a couple words? Thank you for coming on.

This is interesting. It's easy for me to say because I'm not in Florida and I'm not involved with your chapter, although these programs are great. I'm wondering, and I'm going to follow up with Stephen with some other ideas for Michigan, but I'm wondering if this is something that the Florida NAEMSP chapter could certainly share with its members. Maybe working through your Assistant Secretary of health, make it something that EMS does as a community education program.

Right. That's the kind of ideas I'm thinking about. I'm Thinking about.

Because we spend so much money, the state of Florida and all across the country, they throw so much money towards services for addiction and so forth. But we kind of forget. We've forgotten about just some of the basics of care, like Paul said, and treatment and respect. And so Stephen, who Dr. Kramer is talking about, is Dr. Shepke, who is basically the number two guy for the state of Florida. He's the Deputy Secretary of Health. And he, he has been a champion of this cause for much longer than any of us have been on this call. Maybe besides you, he's even gotten to the point where he's open. He's converted an entire ER so that all the patients who kind of fit this category, instead of them going to a random emergency department, we transport them there where they get the care that they deserve by people who know how to treat them, and they can get initiated on Suboxone, like you had mentioned in your story.

And we have, we have. So we do have people at the state level who care about this topic. And I think this is just another angle of importance so that we actually can treat these people with dignity and respect. And actually, like Paul, Dr. Pepe had mentioned, Ken has a picture of a guy who is at the bottom of the barrel. And because he was treated well by EMS and kind of, he got back on the tracks within three weeks, he's cleaned, he's shaving, he's back in his apartment again, and he got his life back. Like the story you mentioned with that patient that you visited and just had a baby. Right. So sometimes all it takes is one person in the back of an ambulance to make that happen. And so I think that this, this.

What you're talking about has, I think, big implications because it doesn't cost any money. And it just, it just takes people to align the department with. This is how we treat people. Right. So I love it. We only have a couple minutes left. Any other final comments or any. Steven, if people wanted to reach out to you, what's the best way? Oh, before we do that, Dr. Kim Landry from the Panhandle. Kim, go ahead.

Hey, yeah, great topic, great discussion. But, you know, this also extends to the handoff at the hospital. I get so many reports from my crews who are standing on the wall or waiting to offload patients, and the, the staff from the hospital will have kind of the same kind of poor attitude toward these patients and stuff. So it's not just with ems, but it really is impactful at the hospital. And patients often complain to our medics when the nurses kind of walk away about how bad they feel because they're in the condition they're in. And the hospital staff kind of picks up on that as well and treats these patients with not. Not too kind.

Well, Kim, what you're saying is, like, essentially, it's almost like taking a patient with abdominal pain to the orthopedic surgeon. Like, it's almost like these people, we're bringing them to a place where they're. They're explicitly getting the wrong care, because the pain people there either have this weird concept or they haven't been trained correctly. So I love that idea about getting the alignment at the hospital level, too.

Yeah. One thing I would also just venture is that one of the things I did over my career is that I developed relationships with providers and nurses that I thought were good to patients that were in this situation. And I would often make it my goal to hand the patient off to both the nurse and doctor that was working at that time that I thought would be the best for them. And in this case, actually, that I shared, the nurse and the doctor that I was able to hand off to took my. Sort of took the baton and continued it on. And I think that also makes a huge difference. I'm glad you brought that up. Is that I. Actually, one of the people who I consulted with on this project delivers a stigma training to nurses across my area of the state in Western Massachusetts, and she's kind of taking it from a nursing approach. And so I think it complements that well. But if you don't have it being done towards nurses, then you would kind of be missing that component. So that's a very good point to bring up.

Excellent. Well, Steven, thank you so much. We've reached the bottom of the hour. Dr. Pepe, go ahead.

Sorry about that. So I learned a lot about from Brian Doris, who did theater of war. And he started out because he was in hospice with. In a sense, he was a hospice worker, for one, his longtime girlfriend who was dying, and then later his father. And there's this kind of thing where, you know, you're supposed to be a good person, and yet they're treating you because they're dying and they're miserable and they're often treating you badly. So there's this thing like, well, screw you. A kind of mentality could come in at the same time you're feeling guilty. So when these people come in to me treat you poorly, just think about why and the circumstances in which they're coming from and try to be patient. Unlike the hospice person, we don't have to deal with them for real long. But, you know. But I just want to put in perspective that it could be something along those lines of remembering they're feeling miserable and it's our job to help get them back on track. And it's possible. And you. You see it right in front of you. All right, I'm Paul Pepe and I prove this message. Right. I'll see you going to the other side. Yes. Remember that Today's CME was 15315. 15315. Thanks. Thanks for giving the CME there. Okay, Stephen, take care.

Bye.

Bye. You're welcome.

Thanks, Paul. Thanks, Paul. That was great insight. All right, excellent. So let's see. Hopefully Angus is on the line. We're going to switch over to the Eagles call. But Stephen, give us your last words and I'll be sure to put this recording on our YouTube channel. But take us away and give us your last final thoughts.

Yeah, no, I think it was great. Thank you so much for having me. And feel free to reach out by email or Twitter or whatever is easiest for you and very responsive. So I'll get back to you and. And let's try to make a difference for people. This is why I'm in this field. I got burnt out in EMS and I took a change because I wanted to get upstream. And so that's where I am now. And this is the whole purpose of what I'm doing. So appreciate it.

You can tell me your email and I'll type it in real quick.

It's Steven. S T E P H E N Murray. M U R R a y m c.org.

Okay, I put in the chat for everybody. Appreciate it. Let's see. Let's see if Dr. Jamison is available to take us over to the other side. If not, I'll try and figure out how to do this from.