EMMC developed bath salts protocol by trial and error

BANGOR, Maine — Users of the drug bath salts who are out of control when they arrive at Eastern Maine Medical Center and are a danger to themselves or others sometimes are given medication to paralyze them until the dangerous street drug they’re on wears off.

That is just one of many treatment techniques that have been developed over the past year as doctors and nurses at the region’s largest hospital treated poisoned and overdosed bath salts users, Dr. Jonnathan Busko, an EMMC emergency room doctor, said recently.

“We know what works and we use what works,” he said, standing inside a patient room in the emergency department’s psychiatric unit, where bath salts users are placed.

The room, which magnetically locks when in use, is devoid of all equipment except for a rolling bed. It has electrical sockets for emergency equipment that can be rolled in at any point, and a small sink is mounted in one corner.

Paranoid and delusional bath salts users have been known to use just about anything as a weapon and sometimes feel so threatened they attack the people trying to help them. Health care providers must constantly be on guard, said Jim Raczek, vice president and chief medical officer of EMMC.

“It’s a balancing act,” he said.

Hospitals from around the state that want to send bath salts patients who are in severe crisis to EMMC for specialized care also may have to temporarily paralyze them for the trip, said Busko, who also leads the region’s ambulance services as the Maine EMS Region IV medical director.

“These people — to be safely transported — will need to be medically and physically restrained,” he said, adding that ambulance and hospital officials still are ironing out the final protocols for transporting such patients. “Because of the risk of explosive responses, the [sending] hospital needs to put in a breathing tube and send them up as a critical care patient. If you look in the back of an ambulance — everything is a weapon.”

If a person on bath salts comes into contact with police officers and they determine the drug user should be taken to a local hospital, they typically accompany the patient there.

But if officials at a small local hospital, for example, decide that the patient needs treatment at EMMC and they medically paralyze the user, local police would not have to follow the ambulance to Bangor.

“In every case, [drug users] would go to their local emergency room and be treated” first, Busko said, adding that hospital staff will determine if the patient needs to go to Bangor.

First-hand experience

Bath salts incidents in Bangor alone increased from three reports in May of last year to more than 100 in the month of September.

With up to a dozen people seeking treatment daily last summer, Bangor-area medical professionals got a lot of first-hand experience that they subsequently shared with doctors from as far away as California.

“This is not what we wanted to be famous for,” Busko said. “This is truly a major illness [nationwide].”

Bath salts, a powdery substance that looks similar to cocaine, came to the U.S. after first surfacing in Europe. It has caused users in the Bangor area to gnaw at their own skin trying to get at invisible bugs, to arm themselves with weapons and climb into ceilings fearing people are after them, according to police reports.

The way EMMC doctors and nurses, local ambulance crews and sending hospitals have dealt with out-of-control bath salts users has changed dramatically in the year since the lab-made drug first appeared on the streets of Bangor. Use of the hallucinogenic drug, which was outlawed in Maine back in July, has now spread statewide.

When bath salts users first began arriving in the spring at EMMC’s emergency room seeking treatment for the dangerous side-effects of the drug, doctors prescribed medications typically given to those with mental illness, Busko said.

“We started by using medications we would for psychotic patients,” he said. With daily trial and error, “what we found is we were underprescribing and were not using the right medicines.”

The benzodiazepines worked moderately well with bath salts users who were agitated but did little to help those who were out of control, Dr. Karen Simone, a toxicologist and director of the Northern New England Poison Control Center in Portland, said recently.

“Lorazepam and other benzos were used in large doses and that was just not cutting it,” she said, adding that antipsychotic drugs were used as a secondary agent when the benzodiazepines were ineffective.

Doctors dealing with bath salts users with superhuman strength and no pain threshold need a medicine that works fast and chose midazolam, a sedative in the Valium family that causes drowsiness and relieves anxiety.

“Within five to 10 minutes we’re done. They’re secure and chemically sedated and we can go back to what we were doing,” Busko said. “In the extreme cases — ketamine [is used]. It doesn’t interfere with breathing, heart rate or blood pressure and within three minutes we see the effects. That stops them and the midazolam keeps them sedated.”

Ketamine, an anesthetic, lasts about 20 minutes, and by then the midazolam will have kicked in, the ER doctor said. Some patients are in the ER for hours, others for days.

“If they continue to be delirious, we admit them into the hospital,” Busko said. “We’ve found that to be the safest and best way to deal with those patients.”

Bath salts users who are in severe crisis — those in a state of excited delirium who are a danger to themselves or others — are put into a medically induced sleep.

“In the most extreme cases, we paralyze them, put in a breathing tube and put them in ICU,” Busko said. After a number of hours — six, 12, 24 — in intensive care, “you wake them up. You do an assessment, and if they are still having a reaction you put them back under to let their body take care of the bath salts.”

Patients who are severely agitated cannot be physically restrained until after they are sedated, he said. When bath salts users are agitated they have an increased heart rate and high blood pressure and any release of adrenaline puts them at risk of cardiac arrest. Once a patient is sedated, the risk decreases and physical restraints can be used, Busko said.

“There are at least three paralyzing drugs [doctors] would typically use” to put a user under, Simone said, listing succinylcholine, vecuronium and rocuronium. “There are various reasons for choosing each one.”

The Bangor hospital has three emergency psychiatric rooms that are reserved for bath salts users and four of the six critical care — or trauma — rooms also can be quickly converted, if needed.

“It’s not uncommon for these patients to change from being calm to violent” in seconds, Busko said. “These patients will fool you. We never want to let our guard down.”

“Oftentimes they clear up and they don’t want to be here,” the doctor added. They look fine, but “we know there can be relapses without redosing for 24, 48 and 72 hours afterward.”

It’s up to doctors and staff to decide how long to keep patients at the hospital.

“It’s not a perfect system,” Busko said.

Incident at Pen Bay

Bath salts took Bangor by storm in early 2011, and waves since have spread throughout the state, hitting the Rockland area of Knox County especially hard, police and hospital officials have said.

EMMC and hospitals all over the state have informal partnerships in place to transfer to Bangor critical care patients who suffer heart attacks, strokes and other serious illnesses that can’t be readily handled by the smaller hospitals, said Raczek. The same is also true of some bath salts cases. Penobscot Bay Medical Center in Rockport has contacted EMMC about sending bath salts patients in crisis to Bangor, Raczek said, adding that the rules would be the same for all sending hospitals.

The discussion was instigated after a teenager on bath salts tore apart a Pen Bay special care room in October, destroying more than $30,000 in medical equipment.

Only the most serious bath salts overdose cases will be transported from outlying hospitals to Bangor.

Police use a side door at EMMC to bring bath salts users directly into the psych rooms, which allows them to avoid taking the drug users past patients in the emergency room’s waiting area.

“We’ve become sort of used to this, but this is very, very hard on other patients,” Busko said. Oftentimes “people are brought in by police screaming and wailing about,” the doctor said.

“They are very distracting,” Raczek said.

The availability of bath salts decreased significantly with the state and federal bans that took effect last year, local police officials say, and its cost has jumped from about $30 per gram to $100.

Medical personnel at EMMC are seeing the effects of those changes.

In October, the hospital was seeing an excited delirium patient every two or three days. Nowadays it’s “one every two or three weeks,” Busko said.

The number of patients who arrive at the hospital daily for care associated with bath salts use also has dropped off by about half in the last couple of months.

Even so, “we’re still seeing three patients a day on average,” Busko said.

That means that anyone who goes into the EMMC emergency room on any given day has a good chance of running into — or possibly just hearing the rantings — of a person who is having a bad reaction to bath salts.