# "Candy-flipping"



## dixie_flatline (Sep 24, 2013)

Anyone familiar with this?  Our fire dept provides coverage for the large outdoor musical venue in the area and at the big festivals this summer we have run into multiple patients who apparently combined MDMA and LSD and _lost their goddamn minds_.

They start roaming wildly around the grounds and are visibly 'out of it'.  Eventually they shed all of their clothes, at which time security/police usually intervenes.  All 4 that I have seen exhibit the same 'symptoms' - they rapidly swing from aggressive/manic to sedate/chill, almost on a clock, about every 30-45 seconds.  They have moments of seeming clarity, then spells where they're screaming the lyrics to a song or _rapidly_ rapping about the universe, peace, love, sex, or what have you.

They are resistant to pretty much all methods of restraint that we have at our disposal - they fight at handcuffs/cravats/zip-ties to the point that they are bleeding pretty heavily from any kind of restraint.  Holding them down takes a solid 6-8 people.  We loaded up an especially aggressive patient with 5mg of midazolam and 5mg of haldol before transporting him to the ED (which was 1 mile away).  At the ED we added 50 of benadryl, plus some valium and ativan for good measure, and he still broke 2 of the soft 4-point restraints before eventually going down.  

Anyone out there have more experience dealing with recreational pharmacology?  We have been lucky so far that no one has been hurt (provider, patient, or bystander) but after seeing the same trip over and over, I'm curious about other options or experiences.  Overall it reminds me of when PCP was big.


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## DesertMedic66 (Sep 24, 2013)

We do medical for a pretty huge music festival (100,000+ people per day for a total of 6 days). We get a lot of drug usage at the festivals. As far as violent patients go, we don't get very many at all. I think this year we had 1 violent guy who was physically restrained and our on site doctor attempted to chemically restrain him with no luck (I don't know what medications or dosages he used but I know he didn't feel comfortable giving any more to the patient. 

Most of the patients we deal with are non violent. Even our really bad acid trips tend to not be violent.


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## dixie_flatline (Sep 24, 2013)

DesertEMT66 said:


> We do medical for a pretty huge music festival (100,000+ people per day for a total of 6 days). We get a lot of drug usage at the festivals. As far as violent patients go, we don't get very many at all. I think this year we had 1 violent guy who was physically restrained and our on site doctor attempted to chemically restrain him with no luck (I don't know what medications or dosages he used but I know he didn't feel comfortable giving any more to the patient.
> 
> Most of the patients we deal with are non violent. Even our really bad acid trips tend to not be violent.



Yeah, we have been covering events for years and this is the first season that we've had patients like this.  Normally we just deal with lots of ETOH and the occasional kid who tries too much of whatever is popular that day (one concert it was reported that someone was giving out "hash cupcakes" - what was in them, I don't know, but a lot of 15-18 year olds got pretty ill).


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## DesertMedic66 (Sep 24, 2013)

dixie_flatline said:


> Yeah, we have been covering events for years and this is the first season that we've had patients like this.  Normally we just deal with lots of ETOH and the occasional kid who tries too much of whatever is popular that day (one concert it was reported that someone was giving out "hash cupcakes" - what was in them, I don't know, but a lot of 15-18 year olds got pretty ill).



Our concert is known for drug usage. We get everything from special brownies to Molly to acid to cocaine to meth and everything in between.


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## technocardy (Sep 24, 2013)

I've never heard of that being done, sounds like an interesting combo though.

A few months ago there was this guy that was brought into our Level 1 Trauma Centre who was under the influence of some god awful drug, I never found out what it was. He was this short guy, but looked like a mini Arnold Schwarzenegger. It took the 2 medics, 4 security and a few nurses to hold him down long enough for hospital security to apply the 7 point Pinel restraints. 

Whatever he was on, was sure one helluva drug.


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## Tigger (Sep 25, 2013)

dixie_flatline said:


> Anyone familiar with this?  Our fire dept provides coverage for the large outdoor musical venue in the area and at the big festivals this summer we have run into multiple patients who apparently combined MDMA and LSD and _lost their goddamn minds_.
> 
> They start roaming wildly around the grounds and are visibly 'out of it'.  Eventually they shed all of their clothes, at which time security/police usually intervenes.  All 4 that I have seen exhibit the same 'symptoms' - they rapidly swing from aggressive/manic to sedate/chill, almost on a clock, about every 30-45 seconds.  They have moments of seeming clarity, then spells where they're screaming the lyrics to a song or _rapidly_ rapping about the universe, peace, love, sex, or what have you.
> 
> ...



This was a fairly common practice where I went to school, which is in itself slightly terrifying. 

I think hard restraints are an absolutely terrible idea for patients under the influence of most psychedelic drugs, our cops would generally not handcuff these patients because it significantly increases their anxiety as well as causes additional and unnecessary injury. In most cases properly applied (the usual hang up right?) soft restraints are more than adequate so long as they are anchored properly. Chemical restraints are obviously a better  choice if available.


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## technocardy (Sep 25, 2013)

> This was a fairly common practice where I went to school



So _that's_ how you get through EMT school :lol:


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## Anjel (Sep 25, 2013)

I haven't run into anything like that. I've only had one pt who said he took 2 Molly's. He was just throwing up everywhere and was super hot and sweaty. 

As far as out protocol goes. I'd be able to give 10mg of versed IM pre radio. And could call for more.


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## the_negro_puppy (Sep 26, 2013)

Dont forget many kids poppings 'ecstasy' pills or 'molly' caps but be taking stimulant analogues instead of the real deal.

Everything from:

MDEA
MDA
Mephedrone
2cb
DXM


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## kcfiredan (Sep 26, 2013)

I have worked a festival for the past 10 years that is also known for its drug use.  We see the same thing,  we also see a lot of "hippie flippin" which is the combination of LSD, mushrooms and ecstasy (MDMA) and or Molly (mda).  We see a lot of the same reactions to the drugs with patients being violent and naked.  We see this probably 20-30 times during the week long festival.
The problem I have noticed is that people want to try something new and buy drugs from someone at the festival and end up with something different than what they wanted to buy or end up with a completely different experience than they were expecting to have.  We had a group called Dance Safe there a few years ago and they would test your drugs before you took them to see what they were and most ecstasy and Molly tested as bath salts or one of the new 2C_ line of drugs out there now.
One thing I have learned is that people in this altered mental status feed off their surrounding and your reaction.  If it's loud and crazy with a bunch of people around you will have a violent patient but if you can get them to a quiet area and try and talk to them in a nice reassuring way letting them know your there to help things seem to go better.  
As for restraining I agree hard restraints are not the way to go.  We use the old tried and true kerlex method on all 4 limbs.  We restrain them to a spine board for transports.  We have a md on site and take these patients to him.  He usually uses a combination of haldol and Ativan to sedate the patient and let them sleep it off for about 6 hours.  
A couple of websites for some information on the drugs is erowids vault , dance safe , and street drugs.
Keep it safe.


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## EMT B (Sep 26, 2013)

one of the medics i work with said that when you use the cravats to tie a patient down, cross their arms first, so the right arm is tied to the left railing and the left arm is tied to the right railing. he said typically people wont have the strength in the right muscles to harm themselves tht way.


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## dixie_flatline (Sep 27, 2013)

EMT B said:


> one of the medics i work with said that when you use the cravats to tie a patient down, cross their arms first, so the right arm is tied to the left railing and the left arm is tied to the right railing. he said typically people wont have the strength in the right muscles to harm themselves tht way.



To be clear, we aren't allowed to use hard restraints - those are always applied by security or law enforcement, with us generally trying to transition them to soft restraints.  We usually end up tying them to a long spine board, with one hand up, angled over their head, and one hand down at their side.


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## medicasaurus (Oct 1, 2013)

I have worked at a 15000+ person 4 day music festival for 3 years now. From what I have seen the chemical restraints (ativan/halodol in particular) seem to work quite well and keep the agitation down. I know this has already been said here but often the environment of a medical tent is not beneficial. At the event I work at they provide a quiet area for people to go sit/lay down and relax which tends to calm many down before it gets to be an issue. Majority of the "serious" cases end up being treated with ativan/IV fluids and a nap. 

I would recommend pillreports.com and Erowid to learn a bit about whats in these pills. My guess is that it is  rare that "molly" is mainly MDMA.


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## broken stretcher (Oct 1, 2013)

Interesting read... 

http://www.kissmyangeles.com/view/story/finding_molly


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## Jon (Oct 1, 2013)

The scenario sounds like classic excited delirium. The whole "getting naked" is usually due to hyperthermia, and that's been thought to be a contributing factor to the delirium, because they are cooking their brain. Sedation and temperature control is the current preferred method of treatment.


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## Aidey (Oct 1, 2013)

Jon said:


> The scenario sounds like a drug overdose. The whole "getting naked" is usually due to hyperthermia, and that's been thought to be a contributing factor to the delirium, because they are cooking their brain. Sedation and temperature control is the current preferred method of treatment.



 FTFY. 

Excited delirium is not a diagnosis, it is a cop out. These patients have a specific and known etiology behind their symptoms, illegal drugs.


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## Jon (Oct 1, 2013)

I'm going to disagree. Not all drug overdoses are the same, and only some result in ED. 

http://www.jems.com/article/patient-care/excited-delirium-strikes-witho


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## Aidey (Oct 1, 2013)

Jon said:


> I'm going to disagree. Not all drug overdoses are the same, and only some result in ED.
> 
> http://www.jems.com/article/patient-care/excited-delirium-strikes-witho



Right, just the stimulant overdoses. Especially in people with undiagnosed heart conditions like long q-t.


And an obese man restrained lying prone stopped breathing after extreme physical exertion? That's a crap example even for JEMS.


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## usalsfyre (Oct 2, 2013)

Restraining these patients is a good way to kill them via hypertermia and massive metabolic acidosis (interestingly, these patients are severely hypoxic, no matter how much O2 you give them or what your pulse ox says. This is why physiology is more important than numbers) . Chemical restraint via B52 (Ativan and Haldol) or ketamine is the way to go. 

I know "wandering around naked" is far from ideal but I do wonder if security's reaction to this is causing the violence.


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## dixie_flatline (Oct 2, 2013)

The two deaths in New York were confirmed as hyperthermia secondary to overdose.

http://www.rollingstone.com/music/news/electric-zoo-deaths-confirmed-as-drug-overdoses-20130913


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## the_negro_puppy (Oct 2, 2013)

dixie_flatline said:


> The two deaths in New York were confirmed as hyperthermia secondary to overdose.
> 
> http://www.rollingstone.com/music/news/electric-zoo-deaths-confirmed-as-drug-overdoses-20130913



This is where harm reduction and education will save lives. Zero tolerance doers not work.

The patients did not die from overdosing, they died from environmental factors combined with the effects of the drug. If partying teens could somehow be better educated about correctly hydrating, resting etc and when and how to get help there would be less deaths.

Instead authorities drive a zero tolerance approach, arresting a tiny fraction of people taking drugs into the festivals, meanwhile thousands party with a variety of substances inside.


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## Pkreilley (Oct 12, 2013)

The key to dealing with these people is be chill. If you can put yourself at ease, then they will become at ease, and everyones life is much improved.


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## NomadicMedic (Oct 12, 2013)

Pkreilley said:


> The key to dealing with these people is be chill. If you can put yourself at ease, then they will become at ease, and everyones life is much improved.



These people don't care if you're wearing a pink leotard or dancing the rhumba. They're under the influence of mind altering chemicals, which is why they need sedation and/or chemical restraint for safety's sake. I agree that a calm demeanor is important, but they key is managing them effectively. Sedation, a safe environment, temperature control and airway management.


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## Pkreilley (Oct 12, 2013)

DEmedic said:


> These people don't care if you're wearing a pink leotard or dancing the rhumba. They're under the influence of mind altering chemicals, which is why they need sedation and/or chemical restraint for safety's sake. I agree that a calm demeanor is important, but they key is managing them effectively. Sedation, a safe environment, temperature control and airway management.



You say mind altering like anything altered is dangerous. I mean, they must have been, at one point in the trip, happy and harmless, because they were dancing and got naked. I don't know about you guys, but I only get naked in public when I'm ecstatic. There must have been a stimuli to change the mood, i.e. a cop or medic who didn't understand the mental state of the pt./how to deal with psych patients in general. Not pointing fingers, but I have seen this scenario play out far too many times.


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## chaz90 (Oct 12, 2013)

Pkreilley said:


> You say mind altering like anything altered is dangerous. I mean, they must have been, at one point in the trip, happy and harmless, because they were dancing and got naked. I don't know about you guys, but I only get naked in public when I'm ecstatic. There must have been a stimuli to change the mood, i.e. a cop or medic who didn't understand the mental state of the pt./how to deal with psych patients in general. Not pointing fingers, but I have seen this scenario play out far too many times.



You're telling me you've never seen a drunk person quickly go from happy to violent? I know we're talking more about other drugs here, but the same certainly applies. These people are simply unpredictable. There's a fine line between "good trip" and "violent insanity" for people on these drugs, and it's not always a bad encounter with someone in authority that changes the mood.


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## Pkreilley (Oct 13, 2013)

chaz90 said:


> You're telling me you've never seen a drunk person quickly go from happy to violent?



That's like comparing epi and D50. Completely different classes, completely different effects chemically, neurologically, and experientally. I understand where you're coming from, but like I said, the authoritative stimulus is going to be the main changing point in the demeanor of those "tripping".


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