Life is not a permanent condition

Life is not a permanent condition. Mountains rise from the ocean. Lakes turn into deserts. You will not be what you are today, tomorrow. The only thing you can depend on is change.

The Other Side

It is hard being on the other side.
Twice in the past few months I've had a family member near death with a medical problem. I've felt helpless, and  worse.

First my wife's father - and my next door neighbor -- was hauled into the hospital by ambulance while we were up huckleberry picking. They worked him up for chest pain, but really it was upper right quad pain with vomiting after eating corned beef hash. I know -- gallbladder right?  Seems the hospital they took him to (not my hospital) never even worked him up. He got an EKG and some morphine and zofran in the ambulance. They did a PO fluid challenge and sent him home.

I had to talk him into going to see his provider, who set him up with an ultrasound for stones. No stones, but he kept getting worse. I didn't want to be intrusive, so I didn't check on him -- and anyway I was busy working. He continued to get worse. Finally he went in for a follow up, got a CT and was recommended to a surgeon at another hospital. His gallbladder had burst, and he'd been walking around for two weeks like that getting septic. The surgery was massive. He was on TPA for two weeks and went home with JP drains. He's doing better now.

A few weeks ago my mom called to tell me my sister was in the hospital. She had a cough that her doctor thought was pertussis. Follow up Xray showed shadows, CT showed fluid building up around her heart and lungs.

I visited her in the hospital while she was getting her tests and fluid drained from her lung. She was across the hall from where my mom recovered from her cancer surgery one year ago. Her husband is an RT, he and I knew too much, based on the tests, based on the language that they used. She was getting worked up for Cancer. Mindy and I talked about it. She had been my mother's caregiver exactly a year ago when mom was fighting lung cancer. She knew the drill but mom's cancer had been caught early and by accident.

"You know it's bad when you doctor calls you personally and says I'm sorry and starts sobbing on the phone," Mindy told me. "All my doctors start with an apology. I always thought I'd get cancer, it seems like everyone does, but not this early. Not when I'm this healthy."

Her cancer is stage 4. If she is lucky and with chemotherapy, she may live to see her 16 year old son graduate from high school.

I feel helpless. I don't know what to say or do. So I talk to her as a patient when she asks a questions and like a brother who loves her when I can't do anything else. I can explain things when it hurts. I try to cry when she's not looking.

The history of the Dainese airbag system

Regulation vs. Self Interest

Interesting article by Tim Noah at Slate (Anesthsleazeology) regarding the inter-profession conflicts and how they influence healthcare regulation. Noah, like most writers, is pretty confused about a lot of things (the difference between RNs and CRNAs for example) but he brings up a couple good points about the future of healthcare. Alabama  is proposing regulations that would prohibit CRNA's and NPs (and presumably PAs) from doing interventional pain management.: It states:  "The interventional treatment of pain may be performed and provided only by qualified, licensed medical doctors and doctors of osteopathy" because it "constitutes the practice of medicine."


Of course CRNA's do a lot of work in rural areas. I worked at a rural hospital that had a busy surgery running all week. We used nothing but CRNA's and most were fantastic. Noah says the Alabama law is born out of a conflict between CRNA's and Anesthesiologists.

 Unsurprisingly, the Alabama medical board's proposed rule arose from a complaint by an anesthesiologist about a "disturbing situation occurring in several facilities in Alabama where … [a CRNA] was providing epidural steroid injections to patients." The anesthesiologist claimed this practice threatened patient safety and asked the Alabama Board of Nursing to stop it. The state nursing board ruled that the anesthesiologist appeared to have an economic interest in preventing nurses from performing these procedures, said the nurses were authorized to perform them and had been doing so for some time, and told the anesthesiologist to buzz off. The spurned doctor got a more sympathetic hearing from the more physician-centric State Board of Medical Examiners.

There's no evidence that CRNA are any less safe in performing the interventions in question, Noah writes. Indeed he cites evidence to the contrary.

Earlier this year, the peer-reviewed journal Health Affairs ran an article under the self-explanatory headline "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians." The article drew on the experience of 14 states that let nurse anesthetists work unsupervised by doctors when treating Medicare patients.  

Advanced practice nurses are often seen as a solution to two of the big problems in the American healthcare system - cost and access to primary care. CRNAs are well paid, but cheaper both to educate and to pay than MDs. There's also the question of access, Nurse practitioners are increasingly becoming the only accessible primary care providers because more and more MDs specialize and avoid primary care. Similarly, you're going to see more CRNAs out in rural areas that cannot afford to have Anesthetists.

The notion of allowing nurses and doctors' assistants to perform routine medical tasks in order to reduce medical costs and make certain services more widely available is controversial only to the particular doctors whose economic interests are at stake (and not even always to them). It has no discernable left-right valence, and the FTC has promoted it under presidential administrations both Democratic and Republican. 

Volunteers Wanted

The musty old Grays River Grange Hall had standing room only. Yet, I sat with a handful of others at the front of the room, in two rows of old theater seats, staring back at neighbors, family, and friends. Those of us up front were more than a little embarrassed with all the attention. As if we were heroes, I thought, but what had we done? We had joined the Grays River Valley Volunteer Fire Department and completed 140 hours of training to become emergency medical technicians. Two of us had signed up to become volunteer firefighters as well. This community celebration was a way of acknowledging our dedication.

Yet, it was something more, too.

A similar size crowd had gathered in the hall six months before. At that meeting, the news was grim. Without new volunteer firefighters and EMTs to answer calls, we were in danger of losing our ability to maintain these services. For our valley, that would have been dire news indeed. In a community like ours, a volunteer from the fire department is the person who shows up on the scene when you call 911 for an ambulance. After a car accident, volunteer firefighters free you if you are trapped in your car and then provide important emergency care.

We live more than 40 miles from the nearest hospital. Only a few hundred people reside in the Grays River Valley. There is no way we could afford to pay for professional fire and ambulance services. It is cold comfort to know that our community is not alone in struggling to find volunteers. The number of volunteer firefighters has declined nationwide by 15 percent over the past 20 years, while the number of 911 calls they must answer has increased significantly. Some fire departments reported a brief spike in interest after the attacks on Sept. 11, but most still report a shortage of volunteers.

As we work longer hours, commute long distances, we've come to guard our free time jealously - even if it is spent in front of a TV. Meanwhile, training requirements for firefighting and emergency medicine have increased dramatically. More hours of training are required every year.

This valley has long been home of dairy farms, loggers, and fishermen. Yet, as those industries have faded over the past 20 years, it has also become home to people who work outside the area, telecommuters, and early retirees. The EMT class represented the spectrum of people in the valley: two retirees, a dairy farmer, a mother and a grandmother, a worker for the local phone company, a mill worker, and a website editor - three men and five women.

EMT training was four months of classes two nights a week - from 6:30 to 9:30 - and a half-dozen Saturdays for all-day hands-on training sessions. Often I would get home from work, study during dinner, and then be off to class. In the last two weeks before the state certification tests, we were at the fire hall five nights a week - sometimes until 10 or 11. Our need to learn competed with family obligations and postponed vacations.

We gained confidence and inspiration from our instructors' dedication as they, too, put in long evenings and weekends. They, in turn, said that they were inspired by us. In fact, wherever we went in the community people stopped to thank us and to tell us how important all this was.

The veterans have warned that we'll see things that we'll wish we could forget. That too often the call will be to someone's house that we know. That we might often be the best thing on the worst day of someone's life.

So why did I join?

In truth, I guess I was hungry for something. It seems as if there's been a hole inside me for the past two years - dating back to a Tuesday in September 2001. I remember watching the crowds of people lining up to give blood for victims who would never be found. I understood then their need to get out from behind the TV and to do something, to strike against the feeling of uselessness. It took me two years to respond to that inner call. When asked, I joke that I joined the fire department because I realized I'd feel pretty stupid if my house was burning down and no one showed up to put it out.

But joking aside, isn't that exactly why we form communities, cities, states, and nations? We invest a part of ourselves to make something larger than us better - whether it be a volunteer fire department or a nation. Who wants to live in a place where no one comes when you need help? If you don't volunteer - or support those who do - why should you expect others to answer the call? A community isn't a place, it's the sum total of the interactions of group of people. I think that's really what we were celebrating that night in the Grange Hall.

"The thing this tells us about our community, is that we have one," one speaker at the celebration said. "Different people, with different talents coming together when needed, making a commitment to serve each other - that's what a community is. That's what a community does."

In Case of Fireworks....Burn Care Basics

General Information about Burns

One of the most painful injuries that one can ever experience is a burn injury. When a burn occurs to the skin, nerve endings are damaged causing intense feelings of pain. Every year, millions of people in the United States are burned in one way or another. Of those, thousands die as a result of their burns. Many require long-term hospitalization. Burns are a leading cause of unintentional death in the United States, exceeded in numbers only by automobile crashes and falls.

Serious burns are complex injuries. In addition to the burn injury itself, a number of other functions may be affected. Burn injuries can affect muscles, bones, nerves, and blood vessels. The respiratory system can be damaged, with possible airway obstruction, respiratory failure and respiratory arrest. Since burns injure the skin, they impair the body's normal fluid/electrolyte balance, body temperature, body thermal regulation, joint function, manual dexterity, and physical appearance. In addition to the physical damage caused by burns, patients also may suffer emotional and psychological problems that begin at the emergency scene and could last a long time.

Airway Management

In the realm of EMS, from basic First Responder or EMT classes, we are taught about the "ABCs" (airway, breathing and circulation). When confronted with a burn patient, the priorities are no different. Why is "A" such a big issue? If you don't have "A," don't worry about assessing "B and C" because the patient probably won't be alive very long! This is doubly true for the burn patient -- a nasty looking burn can distract us from a potentially worsening airway compromise that could kill the the patient.

When assessing a burn patient, we need to be especially mindful of how the burn occurred, i.e., the mechanism of injury. In many cases, such as explosions or "enclosed space" fires, if the patient is burned on the outside (especially if there are burns to the face), it is likely he may be burned on the inside (upper airway) as well. More important, if the patient is swollen on the "outside," he may also be swollen on the "inside."

Think of how a victim of a house fire must be breathing. Anxiety, fear and hypoxia all lead to rapid breathing of inhaled smoke, with carbon monoxide and various other toxic gases that accompany the superheated temperatures. Airway tissue edema from the heat injury or from chemical burns can quickly lead to a life-threatening airway emergency. This is a crucial consideration, especially in children, who have proportionately smaller airways, as a little edema goes a long way.

Not all burn patients present with airway emergencies that require intubation, especially in the prehospital environment. An alert and oriented patient with no respiratory distress and no visible airway injury is highly unlikely to need urgent intubation. But when there are concerns about airway edema, patients, especially children, should be intubated quickly, before the airway becomes compromised. For us at GRFD #3 -- that means quick consideration of calling ALS.

"How long does it take an airway to swell, and how much will it swell?" The answer to these two questions is essentially, "We don't know." It might help to think about what happens when a finger is slammed in a car door. The finger swells immediately, but more important, it continues to swell for hours after the initial injury. The same idea applies to a burned airway. Burn center clinical educators teach the following: "We can always take the tube out. We can't always put the tube in!"

If the opportunity for endotracheal intubation is missed, much more difficult and dangerous invasive proceedures (such as chricoidotomy) are necessary.

If the patient is in arrest or unconscious without a gag reflex, EMS providers should immediately provide bag-valve-mask ventilation and strongly consider intubation when ALS is available. If the patient is unconscious (but still has a gag reflex), or remains conscious with severe facial burns, intubation in the EMS environment using rapid sequence intubation (RSI) techniques should be considered. If RSI is not an option, then 100% oxygen via face mask should be administered until the airway is definitively secured in the Emergency Department.

Assessment - How Bad is the Burn?

Burns are commonly categorized as First, Second or Third Degree -- or Superficial, Partial Thickness and Full Thickness.

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As you can see in the diagram above (1) First-degree burn reddens the epidermis; (2) second-degree burn penetrates the epidermis and causes blistering; (3) third-degree burn penetrates the dermis and requires careful attention to heal successfully. (Illustration by Jason M. McAlexander, MFA. Copyright © 2007 Wild Iris Medical Education.)

Superficial burns are painful burns that are characterized by inflamed red skin. Though field treatment of superficial and partial-thickness burns is directed at controlling pain, the first priority for all burns is ensuring that the burning process has stopped.

After observing Universal Precautions, any jewelry or clothing that may be retaining heat should be removed, followed by a water or saline flush for most burns. Burns caused by dry lime, soda ash, phenol, lithium, and sodium metal should not be flushed with water or saline. Local poison control or CHEMTREC should be contacted for direction on appropriate management of these patients (PHTLS, 2003).

Once the burning has been controlled, the area should be covered to avoid further contamination. Burns should only be covered by dry sterile dressings. Moist burn sheets, ointments, lotions, or antiseptics should never be used prehospital. Use of moist dressings for large burns can result in hypothermia. Avoid breaking open blisters, as this increases the risk of infection. 

Burn patients should be continually reevaluated for airway compromise. Painful burns may distract a patient from recognizing symptoms of advancing airway edema. Stridor, coughing, singed facial hair, and soot around the mouth or nares may indicate potential airway involvement. All patients who have experienced thermal burns should receive supplemental oxygen to treat possible hypoxia related to inhalation and compromised circulation. We’ll talk about this more when we get to treatment.

Assessment -- Classifying Burns

Burns are classified in two ways: Method and Degree of burn. In other words -- how did the burn occur, and how much was burned.

Methods of Burns

Thermal - including flame, radiation, or excessive heat from fire, steam, and hot liquids and hot objects.

Chemical - including various acids, bases, and caustics.

Electrical - including electrical current and lightning.

Light - burns caused by intense light sources or ultraviolet light, which includes sunlight.

Radiation - such as from nuclear sources. Ultraviolet light is also a source of radiation burns.

Never assume the source of a burn. Gather information and be sure.

Degrees of Burns

First degree burns are superficial injuries that involve only the epidermis or outer layer of skin. They are the most common and the most minor of all burns. The skin is reddened and extremely painful. The burn will heal on its own without scarring within two to five days. There may be peeling 

Second degree burns occur when the first layer of skin is burned through and the second layer, the dermal layer, is damaged but the burn does not pass through to underlying tissues. The skin appears moist and there will be deep intense pain, reddening, blisters and a mottled appearance to the skin. Second degree burns are considered minor if they involve less than 15 percent of the body surface in adults and less than 10 percent in children. When treated with reasonable care, second degree burns will heal themselves and produce very little scarring. Healing is usually complete within three weeks.

Third degree burns involve all the layers of the skin. They are referred to as full thickness burns and are the most serious of all burns. These are usually charred black and include areas that are dry and white. While a third-degree burn may be very painful, some patients feel little or no pain because the nerve endings have been destroyed. This type of burn may require skin grafting. As third degree burns heal, dense scars form.

Determining the Severity of Burns

How badly is someone burned? To determine this we take several things into account.

Source of the burn -Mechanism of Injury (flame, clothes or patient caught fire, flash burn, scald, electrical, chemical). a minor burn caused by nuclear radiation is more severe than a burn caused by thermal sources. Chemical burns are dangerous because the chemical may still be on the skin. Burns occuring within confined space make us suspect possible respiratory inhalation injury.

Body regions burned - burns to the face are more severe because they could affect airway management or the eyes. Burns to hands and feet are also of special concern because they could impede movement of fingers and toes. 

Degree of the burn - the degree of the burn is important because it could cause infection of exposed tissues and permit invasion of the circulatory system. 

Extent of burned surface areas - It is important to know the percentage of the amount of the skin surface involved in the burn. The adult body is divided into regions, each of which represents nine percent of the total body surface. (see the picture below)

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These regions are the head and neck, each upper limb, the chest, the abdomen, the upper back, the lower back and buttocks, the front of each lower limb, and the back of each lower limb. This makes up 99 percent of the human body. The remaining one percent is the genital area. With an infant or small child, more emphasis is placed on the head and trunk. This is called the Wallace Rule of Nines. Another option for prehospital care is called serial halving (“half burnt/half not”) approach. You look at the patient and ask yourself, is the burn greater than half the total body surface area? If not, is it 1/4? Is it less than one-quarter?  This is a simple and yet, pretty effective way to estimate burn size for those of us in EMS. 

Age of the patient - This is important because small children and senior citizens usually have more severe reactions to burns and different healing processes. In children and elderly, always be mindful of potential Non Accidental Injury.

Pre-existing physical or mental conditions - Patients with respiratory illnesses, heart disorders, diabetes or kidney disease are in greater jeopardy than normally healthy people.

Fluid Resuscitation

Intravenous fluids are administered to replenish circulating fluid volume that is lost as a result of not only the burn, but also the massive fluid shifts and edema that accompany most significant burns. As challenging as it is to establish and secure an intravenous (IV) line on a healthy person in the back of an ambulance, imagine how it is with a burn patient.

Once ALS is available, there are formulas for fluid ressusitation which is vital to combat the fluid shifts and shock associated with major buns. Note the time of the burn as accurately as possible as some formulas are based on time from the burn. 

Dressings

Burned clothing can initially be moistened to extinguish heat and then removed. This can be done within the privacy of an ambulance while en route to the hospital. If clothing adheres to the burned body parts, do not attempt to pull it off. Simply leave it in place; any remaining clothing will be removed with the burned tissue during debridement.

While not specifically related to hypothermia issues, it is a good idea to remove jewelry with any significant burn injury. If the patient offers resistance to removing jewelry, explain that the earlier it is removed, the less chance it will have to be cut off later. There is the distinct possibility of the jewelry becoming a tourniquet of sorts as the surrounding tissues become edematous. Another important reason for early removal is that jewelry can retain heat and continue to burn. Even in non-burned areas, patients may later exhibit significant generalized swelling.

Burn victims can easily and quickly become hypothermic. This is due not only to the physical loss of skin (and its thermoregulatory properties), but also from environmental factors such as wet clothing and the ambulance's or ED's cool ambient temperatures. In addition to maintaining a warm environment, remember that wet skin cools many times faster than dry skin. Hypothermia may result in prolonged blood clotting times, hemodynamic instability and even apnea in infants and children.

Infants and small children lose significant amounts of heat from their large heads, so a hat or towel can be applied to the head in an attempt to minimize heat loss. Other interventions, such as turning up the heat in the ambulance or warming blankets, can also help to prevent heat loss in these patients.

Dressings: Dry vs. Wet vs. ...

School-age children are taught that "Stop, drop, & roll" is the first thing to do if they catch fire. Why? Because one has to "stop the burning process." 

Not only is it important to extinguish the flame, but one should "cool the burn, not the patient."  

Is it OK to briefly run a burned hand under cool water? Absolutely. Small burns (e.g., a burn to the hand) can be covered initially with gauze and saline. Wet, cool dressings feel better, and there is very little likelihood of developing hypothermia from a burn to an isolated area. 

However, for transport purposes, the general rule is that once the burning process is stopped, serious or "bad burns" should be covered loosely with dry dressings. This can be accomplished by simply putting clean, dry sheets (sterile if available, but not mandatory) under and over the patient, with a blanket on top to prevent heat loss (even in summer). The rationale for "dry dressings" is that they cover the burn but do not add to potentially life-threatening hypothermia. As a rule, burn centers teach "dry dressings for everyone."

The exception to the loose, dry dressing rule is availability of a product like WaterJel from WaterJel Technologies in Carlstadt, NJ. 

Especially applicable for EMS, this product makes the patient feel better (like a wet dressing would) but doesn't cause hypothermia. Industrial EMS providers have been using this product for several years, and more recently, the U.S. military and the countries of England, Ireland and Germany have begun to use this product almost exclusively for prehospital burn dressings.

WaterJel gelatinous dressings are composed of sterile water and tea-tree oil. The dressing pulls heat from the burn into the dressing (helping to prevent further burn injury) without adding to the potential for hypothermia, as with wet saline dressings. Once the patient is in the burn center, the prehospital dressings are easily removed (they don't stick to the burn) and debridements begun after rinsing away any residual WaterJel with saline.  

As with other issues in EMS burn care, the type of burn dressing used should be guided by local protocols and burn center guidelines.

An additional benefit of this type of dressing, especially for us BLS providers who cannot administer IV morphine, is the pain relief that is frequently associated with its use. In a prehospital burn patient study, more than 70% of patients indicated a significant reduction in pain, while 7% verbalized "total pain relief" solely with application of the burn dressing.20 For ALS providers who may administer morphine or similar analgesics, studies have shown that after Water-Jel dressing placement, less intravenous medication needs to be administered. In addition to the analgesic effects of the dressing, the other active ingredient is tea-tree oil, which is a naturally occurring antibacterial from Australia that can help prevent further infection.

Silver sulfadiazine (Silvadene), or "burn goop," though commonly used for burns in the outpatient and inpatient hospital settings, should not be placed on the burn by EMS or transferring hospitals, as the receiving staff will have to remove the dressings and the Silvadene to assess the burn.

What about blisters? From the EMS perspective, their care is simple: Cover them with a sterile dressing. 

Pain Management

At home or in the ED, pain associated with minor, superficial burns can be treated with topical anesthetics (Solarcaine, aloe vera) and/or oral medications such as acetaminophen, with or without codeine, or ibuprofen. Caution is advised when using topical anesthetics on children, because absorption of large quantities of the anesthetic may cause seizures. Pain associated with significant partial-thickness or second-degree burns is unlike any other pain and can require what most medical professionals would consider "unbelievable and unsafe" amounts of analgesia.

Major burns require a unique approach to pain management. EMS and ED personnel should serve as patient advocates in assuring adequate pain relief. If the patient is in shock, as many are in the subsequent hours post-burn, blood is preferentially shunted to the heart, lungs and brain, and away from the "butt and the gut." Administration of intramuscular or oral medications is not advisable in these patients. IV is the way to go and that means ALS. Along with airway management and fluid ressusitation, pain management is another reason to get ALS activated and on the patient quickly.

With partial-thickness burns, plenty of intravenous analgesia is certainly appropriate. Though true that the actual tissue involved in full-thickness or third-degree burns doesn't hurt, extensive burns that are only third-degree are not the norm. More commonly, third-degree burns are surrounded by second-degree burns, which are exquisitely painful.

With any burn, regardless of severity, the importance of parental or family support and adequate analgesia (from dressings and/or intravenous medications) cannot be underestimated.

What Not to Put On Burns

If possible, avoid icy cold water and ice cubes. Such measures could cause further damage to burned skin. Never apply ointment, grease or butter to the burned area. Applying such products, actually confine the heat of the burn to the skin and do not allow the damaged area to cool. In essence, the skin continues to "simmer." After the initial trauma of the burn and after it has had sufficient time to cool, it would then be appropriate to put an ointment on the burn. Ointments help prevent infection.

The one exception to the "Cool a Burn" method is when the burn is caused by lime powder. In that case, carefully brush the lime off the skin completely and then flush the area with water. 

ALS -- Why call ALS on a burn injury? Larger partial thickness burns are some of the most painful injuries one can experience. We need ALS to give pain relief. Also, fluid loss and shock are huge issues with burns. Fluid ressusitation must begin enroute.

Slate Magazine Challenges AP's Heroin Reporting

In our ED we seem to go through phases with the drugs of choice. These days it is heroin more than meth. Most of them get narcan and then try to leave AMA.

Slate Magazine has a great take on AP's "scare story reporting that new, cheap heroin is causing an increase in heroin deaths.

Drug scare stories are nothing new and are rarely based on any real documentation. Usually the source is local law enforcement and some questionable statistics.

In alarmist prose, the article asserts that the ultra-smack's purity ranges from 50 percent to 80 percent heroin, up from the 5 percent purity of the 1970s, and this potency is "contributing to a spike in overdose deaths across the nation." But reports of high-potency heroin being sold in the United States are anything but "recent." My source? The AP itself. Over the decades, the wire service has repeatedly reported on the sale of high-potency heroin on the streets.

Slate points out that AP's been reporting on high potency smack since the mid 1980s and while AP states new users are getting hooked due to cheaper prices -- AP's own reporting states that the price hasn't changed in over a decade. Moreover, Slate notes that the methodology for defining and comparing heroin ODs is pretty murky (if indeed any sort of methodology was involved.)

As it turns out, death by heroin alone is relatively uncommon, according to a 2008 study by the Florida Department of Law Enforcement and the Florida Medical Examiners Commission. The study (PDF) analyzed the cases of all 8,620 people 1) who died in the state during 2007; 2) whose death led to a medical examiner's report; and 3) who had one or more major drug (including alcohol) onboard when they died.

In only 17 of the 110 heroin-related deaths was heroin the only drug onboard. In most cases of heroin-related death, decedents take other drugs that depress the central nervous system—other opiates, alcohol, sedatives, etc. The dangers of "polydrug use," as some call it, have been well understood for some time. A survey of the medical literature published in Addiction in 1996 titled "Fatal Heroin 'Overdose': A Review" warns against attributing all deaths in which evidence of heroin is present as "heroin overdose."