Episode 2- Interview with Amanda De Leon-Community Medical Services

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Welcome to Pulse Check, Wisconsin. Hello, hello, and welcome back to Pulse Check Wisconsin. Again, my name is Chris Ford. I'm an emergency medicine doctor here in Milwaukee, Wisconsin. And I want to thank you for joining us, which is now our second podcast episode. If you hadn't listened to the first just to provide you some background, what we're trying to do with this podcast is to provide you with some context into what's going on in the emergency department. Some of the things that we see day in and day out, as well as some of the things that we see in the hospital. The Ultimate goal is to provide you with this background and hopes to keep you out of the emergency department, as well as to give you some insight into what you can expect to see when you come to the emergency department. In addition what we want to do is to give you some tidbits of information that you can take back to your families, to your friends, to your loved ones maybe even to your workplace in order to kind of help facilitate some of that preventative care and to keep you safe while you're out in the community. So today's episode. um,is going to kick off like the remainder of the episodes will from here on out. The first one was the intro episode. This one will be our kind of bread and butter presentation. So we'll start out with a case that I'll be covering pretty soon. And the case is going to highlight some of the things that we will talk about later on and kind of delve into a little bit more later on in the show. So we'll cap it off after that with a special guest to kind of help reinforce some of those. um,principle that we discussed and then to give you some information in terms of next steps, things that you can do to help if you have an interest to do so this episode, again, like I said, we will start out with our first case. So with that being said, what I'm going to do is I'm going to turn it over to that case, which will be starting right now. So it's 1030 at night on a Saturday. I get a call from EMS that we have a patient coming in with difficulty in breathing. From the page that we get out, the report says it's a 19 year old female, difficulty breathing we have all the airway supplies available just in case, and our respiratory therapist is there as well. The patient is brought directly into our resuscitation bay. At time of arrival, we learned that the patient is a college student and she was out earlier this evening with some of her friends. She became unresponsive when they got back to their dorm room and the friends called EMS. The patient's friends admit that the patient had been drinking that evening, but it was unknown if she had been taking anything else, if she had any illicit substances they didn't know what kind of medication she had been on in the past. At time of arrival, the patient's vital signs demonstrate that she has a slow heart rate, her respiratory rate, or how fast she's breathing is relatively low in the single digits. Normally, we like to see that around anywhere from 12 to 18 for an adult. Hers were in the single digits about 4 or 5 breaths per minute, if that. The patient wasn't responding to pain. And at time of EMS arrival to the dorm room, they noted that the patient's pupils were, as we call, pinpoint, or very small. They noted that she was having what we call apneic episodes, or episodes in which she was not taking any purposeful breaths by herself when she was in the rig. And they provided some back mass ventilation, or just some breaths by hand for her at that time. The EMS crew very astutely administered Narcan in the field, which is a reversal agent for opioids. They said that they gave her four milligrams of Narcan by nose with a nasal spray. And then once they were able to establish an IV, they were able to give her an additional two milligrams through the IV. They said that the patient remained unresponsive after they gave this Narcan. Occasionally, though, after they gave it, she had some moaning, but nothing really purposeful in terms of talking or moving her arms or legs. By the time she got to the ER, she's still having some significant difficulty breathing. So, myself and the RT made a decision to get everything set up in the room in the event that we needed to place an airway or to provide a breathing tube for her. So, I talked to my charge nurse who was in the room with me and told her to pull up another 2 mg IV of Narcan because it seemed as though she had some response to it. So, we got that set up and we administered the 2 While my respiratory therapist is getting together all the airway equipment, I take a quick look from head to toe to see if there's any signs of any trauma to the head or trauma anywhere else that could be leading to this presentation. As I'm doing that, the patient, still seemingly out of it, has a large episode of what we call emesis or she grows up at that time. So at that time, We were able to suction out the airway to make sure she didn't aspirate or make sure none of this vomit gets into the lung space and At that time I made the decision to place the breathing tube not only to provide her with some oxygen but also to Protect the airway after doing that We were able to draw a lab for the patient. um,we were able to do some additional testing as well. And I discussed the patient with the ICU doctor or the intensive care doctor in order to secure her a bed upstairs as further workup will need to be done when she left the emergency department. After I had that conversation with the ICU doctor, I was able to look at some of the labs that had been sent out. The labs are normal the patient's EKG or the heart tracing that we use look completely normal as well. I was able to look at her previous chart and there was nothing really in her past. She was on no prior medications. Again, the rest of her physical examination was normal. There was no signs of trauma no evidence of any pathology that I could see otherwise. um,no seizure history that I saw on her records as well. However, there's one thing. that came up on the labs that looked abnormal. had sent a toxicology screen for the patient as well, which had just come back. And with the exception of everything else that was negative, the two things that were positive on this patient's tox screen was a positive for oxycodone and a positive for fentanyl. So, there's a lot to unpack in that case. What ended up happening to the patient was she was admitted to the ICU with a breathing tube or an endotracheal tube on the ventilator. eventually Was able to be extubated, as we say, or able to have the tube removed. After about 24 hours or so, she had time to process what ended up being an opioid toxicity or an overdose on oxycodone and fentanyl in this case. The patient was very forthcoming with What she had ingested it ended up being that she got a pill from someone that she knew She took it recreationally. She had no intentions of harming herself when she took it, but more so was taking it just as a recreational means so The patient thought that the pill that she was taking was oxycodone She had had oxycodone in the past and has had Percocets in the past um,reationally. um,was not taking it chronically, but every now and then when she was partying, she said, the issue was that this pill that she took was not only oxycodone. But there was fentanyl, which is a synthetic opioid that was laced in the pill itself. The patient ended up going home, did not have any long term health effects from this fortunately. um,but this case is a case that we see. Commonly, unfortunately, around the country, as well as here in the state, I mean, there was recently a case of a pilot that came into Middleton here in the state of Wisconsin, in which there were was seizure of over 40 pounds of Synthetic opioids or fentanyl And so, fentanyl, opioids these are huge topics that affect our day to day life in the emergency department. Affects a lot of um,your lives as well, you know, you may have family members or you yourself um,be on opioids. Some folks may have addictions to opioids as well. And so it's very important that we touch on this topic and that we discuss it not only as a medical profession, but as a community, as a whole. in order to allow people to know what some of the dangers may be. When I say that this is something that we see commonly, a lot of times, what'll happen is, folks who are either on opioids recreationally, or if they're on opioids chronically, if they run out of medications, we see that sometimes folks will fall back on Other forms of opioids that are more readily available. So either that being, you know, narcotics that are available on the street like heroin or some medications or some tablet forms of what they think is a certain type of opioid like oxycodone or Norco or Percocet and ends up being um,You know, either containing some of that medication that they thought they were getting, some of that opioid that they thought they were getting, but also containing fentanyl. Now, the danger with fentanyl, and we should really tease this apart, too, because fentanyl is something that we use in the emergency department commonly for um,what we call noxious procedures or procedures that will cause patients pain in the long run is something that can be used um,o in presentations like appendicitis or things like, you know, that you'll be seen in the emergency department for that can be causing some pain. But the difference is, is that. Although it is a synthetic opioid, the way that we use it in the hospital system is dosed um,the patient's weight, and it is a micro dosing of what is seen commonly in some of these, street available um,mulations. The reason why fentanyl can be so dangerous. And in the case of our patient that we saw, the reason why she, it was so resistant to, Narcan, which is usually a reversal agent that we'll talk about a little bit later is because fentanyl is up to 50 times stronger than heroin and up to a hundred times stronger than morphine. So you heard me say that. Fentanyl is something that we use for pain in the emergency department. Morphine is something that we commonly will use um,the emergency department as well. And so, this is something that can be up to a hundred times stronger than morphine. And the reason is, is because how it binds to some of the receptors in the brain um,t the opiate medications. will bind to in order to produce um,t analgesia or produce that um,rease in pain that you'll experience. And so, it's not uncommon, unfortunately, that these types of overdoses are deadly, especially if patients can't get to the emergency department. um,and can be deadly in the sense that it can be very resistant to the medications that we use in order to revive people from toxidrome or revive people from the medication overdose. Thing that is bein addressed at this point in time and we'll talk about with our guests coming up is the availability of Narcan in the community. And there are many schools of thought on this topic, but it's no secret that Narcan can be life saving. um,in some instances in which you can't get to the hospital immediately. So there's been a lot of legislation. There's been a lot of social dialogue about how to make Narcan available and where it should be available as well. And so again, we'll get into that with our guest So this information is taken from the November six article in 2023 by shepherd express. com. Essentially in the state of Wisconsin, there more than 1400 opioid overdose deaths. Milwaukee County had around 600 650 of those overdose deaths. And so that focuses some of the severity of opioid use disorder. So what we're going to do is we're going to have Next, uh, guest here. Her name is Amanda de Leon. She's doing amazing things in the community. She works for a group called Community Medical Services in South Milwaukee. She is currently the Community Programs and Integration Manager for CMS. And they offer medications, counseling, and other wraparound support services for people with opioid use disorder. And so with that being said, We're going to turn it over to the interview. for the listeners, could you tell me a bit about yourself, uh, and kind of what your role is in the community? Oh, yeah. So, um, I was born and raised here in Milwaukee. Um, been here all of my life. You know, a little bit about myself. My dad was, um, a police officer, so he retired as a Milwaukee police sergeant. Um, grew up inner city on Mitchell street, just about until I was like 16. So, you know, cops had to live in the neighborhood. So therefore we lived in the neighborhood, which I think was the best decision for me, um, just so I can just be more culturally involved in the community and seeing where, um, things were and just like the injustices, right. That we, we. We had to succumb to it in the communities that we worked in, so, or we lived in, so, yeah. Yeah, no, I agree. My dad, um, kind of in the same vein was a Chicago firefighter. It's the same deal. Like, we had to live within the city, you know, limits and kind of went to Chicago Public Schools and everything else, too. And you bring up a good point in that. You know, if you're living in a neighborhood and you're from the community, you see it every day, people who you interact with every day, you know, kind of succumb to some of the things that we talk about. It kind of gives you that added level of connection to the work and, you know, emphasizes the importance of it. Yeah, and it's like, you could, like, I got to see a lot of different things growing up, right? Because, Um, even though I'm Mexican, I was born here in America, right? So I always considered myself Mexican American, you know, and then when you grow up on the South side, primarily Hispanics, right? And so it was like, I, there was so many things that I had so many adversities that I had to work through. You know, we went to Catholic school until we were in eighth grade and then went to lovely South division when I went to ninth grade. So I went from wearing like poodle skirts and totally kind of sheltered from the world to then all of a sudden I was. You know, all over, um, in a school that you're just immersed in everything. And, you know, and so there was that part of it. And then there's the part of being Mexican American and not being Mexican enough for your Mexican friends and not being American enough for your American friends, because of my skin color. And then the also the added component that trumped it all is the fact that my dad was a police officer, so it was like, you know, I dealt with all of that and it's so it was just. I don't know. So when people say I can't relate to anything, I'm like, you got no, you have no clue. No clue. Absolutely. Yeah, well, I'm glad you made it out of it. I'm glad that uh, you know, you didn't let it let it hold you back You're doing amazing things So could you explain to me like what community medical services is and kind of the role that it plays Uh, and then your role within it Yeah, so, okay, so at CMS, so CMS is Community Medical Services, and we're a medications for opioid use disorder clinic, so we offer all three forms of medications for opioid use disorder, so MLUD, um, that would be your methadone, your buprenorphine products, and Vivitrol. But we couple that with counseling, right? Um, and then there's all these lovely things called state and federal regulations that all OTPs, which an OTP is an opioid treatment program, in Wisconsin have to adhere to. And there's other states too, but Wisconsin is extremely strict when it comes to OTPs, our regulations. They're more strict than the federal regulations, which the federal regulations changed, and we're hoping, hoping, it's a very strong word, that the state will suit, but, you know, we can only get there. We just, we'll get there eventually, but, you know, and the reason why we say that is because rules are meant for a reason, right? But, When it comes to like you're trying to meet people where they're at and provide a holistic approach when the rules are so strict It doesn't it's not meeting somebody where they're at, right? It's not it's not letting them feel like they have any control of treatment so with the new changes, we're hoping that I know Wisconsin would probably be one of the last states to follow suit, but You know with those new changes. We're hoping to see more positive impact on the folks that we serve So within my role, I know I'm a long winded talking person. Oh, no, you're doing great. So, um, community medical services, they, they knew way back when they first started in Arizona that they needed to meet to, um, to, uh, have these folks like me, community impact managers. And we went through so many different. Words and names of our my title has changed by at least 6 times since I've been here, but, um, but our role is to be embedded in the community. Yes. We want to be out there and educate folks at, but they want us in the community to break down the barriers to break down those silos to let everyone know that we should be working together. Instead of separate to be, uh, to provide the best quality of care to these folks that we serve because we know that these folks don't get treated right in the health care systems in the correctional systems and wherever they go to the dentist. So it's finding those system partners that will treat our patients with care. So we can say, Hey, you know, that tooth that needs to come out, go see Dr. Dr. Hernandez, right? They'll get you in. They'll treat you with respect, get that tooth removed, you know, so again, treating patients where they're meeting patients, where they're at and treating them holistically. So that's why they created our role and our role is not funded, right? And that's the same thing for our peer supports. That's not a funded position here in Wisconsin either. So these are like You know, and I hate to say it, but you have to in a business. These are financial hits that a company takes, but they see the reward on the other end of having people boots on the ground advocating for the needs of the patients. So that way they can get the best quality of care that is needed. Um, so, yeah, I mean, that's that's my role in a nutshell. I'm everywhere that I can be. Um, within, you know, my trying to find limitations and healthy boundaries that I don't know what that means yet, but you know, it's, I just, I want to be out there to advocate for folks that don't, that can't advocate for themselves. Right. And when they automatically know somebody who's using right. Oh, we look at them negatively, but if they, if I come at them in a professional manner. They'll look at me and they'll listen to me and then I can send Johnny over there because they've listened to me and that and that's that sounds really negative, but it's an opening. It's an opening that they're able to connect that Avenue. Right. Correct. Correct. So, yeah, well, it sounds like you're coming at it from a couple of different perspectives. Right. And I feel like that. Is the biggest step that we've taken forward in the last, you know, 15, 20 years and that we're removing the stigma of criminalization, uh, behind, you know, opioid use disorder as well as, you know, any other narcotic form, but it looks like you're, you're, you've taken a role, um, that, you know, kind of mixes some like psychology as well as some clinical, uh, background of the two from your educational background. Do you have, um, kind of that duality? How did that go? Yeah. So when I first started Alaberno, I went into school thinking, what are, what is a field that I can go into that's going to make, um, be sustainable for my family, right? Because, you know, I always think about, I can only control what I can do, right? And so, I started at Alverno, nursing and psychology, but unfortunately, when I got through, I think I had one year left, no, a semester left of my nursing, and when I was in my clinical, Back then, you had to start, you had to do 12 hour shifts overnight, and that wasn't going to fit in with my family's structure. So then, I was like, okay, let me do psych. So I switched over to psych with substance use, and through all of that education, and at Alverno, right? We use our eight abilities, they focus on community. And I think that was the, the, the right education for me because of, you know, you never know what the future is going to hold and now look at where I am in the community. So I've been able to utilize all of the skills that I've learned there into the community that I serve. Yeah. And do you feel that, you know, the, the way that things have been going kind of in recent years are kind of increased legislation, uh, going, coming out to provide Narcan to the community. The most recent X waiver, you know, uh, uh, ability that, you know, physicians can prescribe it now without having going through the program. Do you feel like all those things are kind of making, um, uh, moves forward, uh, in the war against opioids at this point? Or I think we are, I would like to think we are, and I'm not being, you know, um, gullible about that, but I mean, our death rate doesn't show it right. Um, I think when I added it up, I think we were at 691 last year and the year before we were at 674. But at the same time, you know, I think like, there's been so many non fatal saves, right? And if you think about how many non fatal saves there have been, and the reason why, is because there's been Narcan in their hands, right? So I don't understand, um, I mean, I understand where people are getting at as far as like, Well, no, Wisconsin has a far way to go. We are way more advanced than any other state we are doing. Like, like they're starting bupe inductions in the field. I mean, come on now that's, that's flipping amazing. Right. We have, um, our fire chief on board with passing out Narcan kits when folks don't want to go into treatment. Right. Cause we know they're going to go AMA. They're not going to. they're not going to want to go to the hospital, They're, they're, they're not thinking that clearly, especially when you come out of an overdose. So, like I said, those Narcan saves, that's, that's been happening because those hope kits are in their hands it's because we're making Narcan, easily accessible. Uh, it's getting it out there, giving them the tools that we need, just like we did, you know, back in, what was it, the 80s when we gave out condoms and, put up clinics for HIV. You know, we, we saw a problem and this is how we're tackling it. I just gave an interview. We talked about before for the news talking about Narcan. But the reason why we did the interview is because there was a recent bus driver that was in Milwaukee County that saved someone's life. Based on, you know, kind of being trained, not only having that training, but having the Narcan available like you spoke to and how that can save a life, right? And like you said, EMS is on board, um, you know, Chief is on board to kind of getting, you know, boots on the ground to make sure that we're kind of pushing these efforts to save people's lives because the same way that you would have, a defibrillator in the community for somebody with heart disease or have an EpiPen in the hands of someone with a peanut allergy, right? Like Narcan is life saving in that step. Right. Yeah, I would, I would totally agree. And that was, um, Abby van handle. I think her name is, I don't know how to spell her, say her last name, but she works with the Cudahy public health and South shore cares, there was, um, an uptick of overdoses in Milwaukee on the Milwaukee County transit system. And so she met with them and then that's how that all started. And now there's, they're, they're implementing that with new driver trainings and all of that because of that safe. So it's pretty darn amazing. Well, one of the things that, I want to take a step back real quick just to kind of talk about that Narcan, talk about some of the medications that are available for people with opioid use disorder. I just wanted to see if you could speak to that a little bit more. Uh, kind of, first off, Narcan and then secondarily, like, what other medications are available that can help people with this disorder? Yeah, totally. So, um, first off, so Narcan, which, you know, Narcan's a brand name, we're trying to use Naloxone now, but at the same time, we know everybody knows the name of Narcan, so, we'll stick with what people will gravitate so with that, as you know, for those that are listening, Narcan reverses an opioid overdose, right? It only works on an opioid overdose. Now, we know that there's other things out there, like the fentanyl, and then like those designer drugs with the isatines attached to them. But any other like tranquilizers, Narcan isn't going to work for. So that's why we always strongly encourage everyone to call 9 1 1. If you find somebody passed out, right, and not responsive in any way, call 9 1 1, because first off, the Narcan might not work, and secondly, it might be some other medical issue, right? There's other things that are going on, you know, they could have a heart attack, or a seizure, or something, right? Some other health issue that you need 9 1 1 there. Um, but Narcan, it has such a high affinity that it clears off those opioid, the opioids that are on the receptors. But the key thing is that I would want everyone to understand that just because you Narcan them doesn't mean that they won't go back into that same overdose, okay? So again, another reason why folks need to go into the hospital because those drugs, the drugs are stronger than the Narcan after the Narcan wears out. It lasts for about an hour tops. So those drugs are still in their system. And eventually it's going to find that magnetic, you know, attraction to those receptors and then they can overdose again. So that is a medication that's. It's to save somebody from an overdose, right? You can't treat people with that, but the three medications that you can use to treat folks for, that have an opioid use disorder, is methadone, right? Methadone's a complete blocker, uh, or not a complete blocker, it completely attaches to that opioid receptor, so it makes somebody feel like they're on something without the high feeling, right? Methadone is the gold standard as well, so, you know, if my kids ever, God forbid, became addicted to opiates, I would be like, get on methadone, because they will feel better quicker and get sober faster. Buprenorphine, it's like, think of a square on that receptor, so it's almost a complete binder, right? It has, um, it's an agonist and an antagonist, so it has a little bit of that naloxone product in there. So that's why folks, when they're sick, uh, or when they've just used and then they try to take a buprenorphine strip, they get sick because it's that naloxone, right? And then Vivitrol is a complete blocker on that receptor. So that's why folks don't typically do well with Vivitrol. But also you have to be sober for about 7 to 10 days. So that's hard to do and everyone's like, well, if they want it, they can do it. Well, hey, new year, new me. Well, how long did it take you to get that box of Oreos out and eat it before? You know, you probably had that box of Oreos out by the third, right? January 3rd. Yep. Yep. And that sugar is, it has the same kind of wheat. You know, there's research that shows sugar addiction. You know, it spikes up that dopamine. We have that same response. So again, When you're thinking about that and you want to judge somebody just think oh, I'm not gonna Oh, I'll just go to the bar and have one beer and then you have three you have four, right? So you have to think about it. It's different It's more of like a brain disease versus the control pull up your bootstraps and stop using. But those are the medications that can be used And an OTP is the only place that you can get methadone for opioid use disorder. So you'll have to go into, a clinic that you have to dose in every single day. Okay? So when people are out there judging our folks that are coming into treatment, Hey, when is the last time you've done something every single day that you were committed to because you wanted to feel better? Okay. And that's for methadone and buprenorphine. Vivitrol obviously is once a month, but Oh, the other medication that we offer is another buprenorphine product called sublocate. So that's an injectable form of buprenorphine product versus the sublingual. But these folks have to come in every single day. You have to commit to them, hopping on a bus. For an hour and a half one way one way to a clinic and that's in snow that's in rain In the heat, it doesn't matter. These folks are that committed that they want to do better And so they're going into a treatment program Versus an office space. So like when you were talking about the x waiver, so like a nurse practitioner a mid a mid level provider or a physician can prescribe folks buprenorphine strips or The sublocate and the vivitrol so they can go into an office Get that medication and if it strips, they'll get like a week's worth at a time. Now some of those clinics do have, you know, the added benefit of having counseling on top of that, because we know medications is a small portion folks need counseling. They've, they did so much that they need to work through in order for them to get on that right, on their path of recovery medication only takes that edge off, but. You've, you've went against your morals and your values. You've done things that you're not entirely proud of, right? You might not have your kids in your care. Having that licensed therapist there will help you work through that and give you more tools in your toolbox for when things get rough. Let me pull that out. What do I need to do right now instead of using? So, you know that works. Um, and so some of those OBOTs will offer that as well. But at an OTP, we always offer it. It's part of treatment. And already, I mean, with that explanation, I'm so happy that I was able to get you on this one because you hit on a lot of good points there, right? And so not only kind of with the medical background of each one of the treatment options as well, the reversal agent of naloxone. But also in the, the change in the understanding of opioid use disorder. I would say very early in my career, you had some old school folks that were there like, Oh, she's back again. You know, we don't want to do this. She just wants narcotics, et cetera, et cetera. And as I've moved on through medicine, you see that that understanding has fortunately gone by the wayside. Because like you said before, you know, these are things that. Folks are trying to get better from. They're trying to put in the work, going through something daily. In addition to, you know, having to go to the clinic to get those treatments, they're still raising a family, right? They're still trying to go to work. They're still trying to take care of all their activities of daily living. So all those things fit into, the whole sequela that is opioid use disorder. That's not only the body, but also, there's some psychology behind this. Some neurochemical effects that folks anybody would succumb to of all walks of life. Correct. Correct. What are your thoughts, speaking of Narcan, about the, there was a lot of media surrounding the Narcan stations that are offered throughout the city. Um, one was talking about, the vending machines at UWM. Um, what are your thoughts about that? And then what are sort of next steps that you can think of from like a CMS perspective that we can do to promote further availability of Naloxone in the community? Yeah, so I think it's amazing that these vending machines are popping up everywhere. We are actually going to get a vending machine. Um, we were, it was supposed to be our Christmas present, but then it was delayed. Yeah, and then we were like, yes, our Valentine's Day gift and not yet. So it's supposed to come in March. Ours will be temperature controlled outside of our West Sallis location. Um, and so folks just go in, hit the VIN number. I want a six and it's all not can right? And then it just simply comes right out. They don't ask any questions. And the great thing that Milwaukee did, um, is listen to the community and by collecting data, so if you had to enter your birth date or whatever, we knew that was kind of a barrier to folks accessing our cancer, those vending machines. So they simply just vented out just like yeah. It's, it's amazing. Um, and again, it's meeting people where they're at, right? If you know, they have a 50 copay, it's Narcan is not going to be, that's like, okay. And even over the counter, I saw it at target for 45. It's 40 in Walgreens, 45. Like there was a coup. Bond for 39 people don't have that like this. Yeah, because you're right now people are worried about how are they putting food on the table? Right, right And now you're you're giving them that dilemma of do I get narcan to save my son who I know is struggling? Or do I go buy meat that will last us a couple of days, right? So that's that's to me. That's a huge barrier in on itself. Yes. Great We got it out in the hands, but that cost is so expensive. So go to the vending machines go to your health departments There's a milwaukee fire if you go Go to any firehouse door and knock on the on the door. They will give out the hope kits. No questions asked. Um, Oak Creek Fire has one as well outside of or inside their station three. I think it is on Pewds. I can't remember, but Station 3 in Oak Creek, um, they have one as well. Um, Greenfield relocated theirs. I'm not sure where it is now. I think it might be in a firehouse. Um, but I just think that getting it in the hands of where people need it is, is vital. And that was how we thought of at CMS. When Narcan direct first started, um, they were like, get out there when you're at these events, if that's the way in of doing Narcan trainings, do the Narcan trainings, we brought Narcan to pride fest, we gave out Jesus. I think it was like. We ran out. The nurses had to keep bringing it. I think we were up to almost 500 kits that we gave out at pride fest two years ago. And I would use, I would use us, right? Because we knew a lot of health departments were, there was still a lot of backlash of them giving it out. So I would say, okay, let me come in as the resource table. I'll bring the Narcan and You can say hey, we brought them here and give us the applause if your community likes it then say hey We brought them here, right? Because I'm all for that because I know that the stigma attached because there's stigma attached to people carrying Narcan There's not one Narcan training that I do not attend that somebody says are they gonna think that I'm a drug user for carrying this And I get a little angry because I'm like, well, who cares if they do think like, there's like a little negativity attached to that. And I'm like, well, no, I said, that's no different than an EpiPen or inhaler, right? You're just carrying it on you because you don't know what's going to happen. You know, you could be at a stoplight and somebody is overdosing. You know, so, you know, you have that and it's good. It's always good to have that then not have it just like cpr training They want everyone trained on it, you know, because you could save a life And I think the most recent reiteration of acls I know it's been a while since the last time I researched it But it looks like they included arcane training in there now like the american heart association is making a big pivot As they should to kind of include that so that the general public knows You know that there's something that's available and something that can save a life Agreed. Yeah. And I think that's amazing that they do that now. I think it is. Yeah. One of the things you mentioned was, um, kind of the partnerships with some of the fire departments, um, in the area of Milwaukee. Um, does CMS have partnerships with the fire departments? And if so, uh, kind of, are you guys kind of given training or given resources in that fashion? Um, all of the above is what I'll say, right? Because the thing that I, again, I really love who I work for. I'm not just saying that because I work, you know, like, this is the place that I work for. They, They pay my bills, right? I truly love who I work for because, um, when Maury, which is the Milwaukee overdose response initiative, when it first started before we were going out, they were like, I went to a meeting and they were talking about their overdose response plan. I gave recommendations and they were like, well, are you going to give us up here? I'm like, well, heck, I don't have a peer, but let me talk to my company and figure out how I can get you a peer. And then I called, I called, you know, we were small then. I called my, my, one of my bosses. I call them all my bosses because they're all ahead of me. And he was like, some, some explicit words. And he was like, let's do this. He goes, I'll worry about talking to the financial people. You tell them, yes, let's get this position posted. This is absolutely amazing. And then that's how we got involved. Right. And again, this is why I love who I work for because there was no money. Okay. Nothing. It was like, Hey. Do you have a peer? No, but let me try to get one. Right. And it was like, but I have no money for you either. Right. So, and it's like, you know what? I don't, I don't care when it, about money, when it comes to, you can't put a value on somebody's life. Right. And so that's, you know, we're involved with the Milwaukee Fire Department. We provide a peer support specialist that goes out with to firefighter paramedics, um, and a peer support. They go out to the non fatal overdoses within 24 hours, right? So if I were to overdose and I told, you know, the fire department to go pound sand, Maury would still come pay me a visit, you know, and I may tell Maury to go pound sand, but guess what? Maury will set up another visit for the following week until I no longer tell him to go pound sand. Right? Right. And that's, it's like innovative thinking like that is what's saving lives. And not only are we involved with Milwaukee fire, we're involved with West Dallas fire, Greenfield fire, um, St. Francis. South Milwaukee. Um, there is that's the nursing there. They're nurse and a social worker in a police department. Um, but we in Oak Creek is coming soon. Oak Creek fire. But it's just again, we're thinking of these innovative approaches to meeting people where they're at and going to their home. How can we help you? Right. Right. It's just, it's just awesome. I love the work that we're doing with our fire departments and our health departments. And again, you're breaking down barriers. Health departments and OTPs never talked before, right? OTPs and fire departments never talked before. And so now we're all looking at it as, hey, Sally has overdosed three times this week. Instead of being always so reactive to it, how can we be a little bit more proactive to make sure she has the harm reduction items she needs? But also, let's give her a little bit of coddling to see where we can send her for treatment. Is she ready? You just might need a hot meal right now. And let's run the Burger King up the road and get her a hot meal. But building that relationship, setting, setting that foundation. So that way, when they're ready for treatment, they can get them into treatment. That's awesome. That's awesome. I love it. It's like, Oh, I was so glad to be a part of that passion project. It's amazing. This is actually it, right? It's a passion product. And you know, that it's something that you can go to work every day. And you know, that you're making a difference in your community. And you know, that the work that you're doing is going to affect. Multiple generations. That's that's the thing that you know, I try to tell a lot of people like when i'm doing advocacy work um, you know the The point of this is opioid use disorder does not only affect that person that affects their family. It affects their kids So this is the generational condition That we can't just criminalize and we can't just, you know, turn into, you know, it's a, it's a them issue, right? So this is all of our issues and affects all walks of life and, you know, Any avenues that we can make to provide the support and make it sustainable. Because there's one thing just to bring, you know, some treatments in there and say, okay, we're gone. See you later. But what you guys are doing is you're creating those avenues for this to be sustainable and we can build on it as, you know, healthcare professionals, as, you know, allied professionals in the community, right? Yeah, and there's that follow through, right? We've connected through these overdose response teams. They've connected them to these resources, right? But that doesn't stop that day, right? Just because we got Sally into treatment, we don't say, okay, good luck, see you later, Sally. They still follow up with Sally. Right, right. You know, and so it's just, it's amazing, just that hand holding and that coddling because you mentioned families. Families have given up, right? And I will never recommend a family It is really hard because, you know, there's, in my life, there's, there's individuals that have been struggling with substance use, it plays a huge toll on the family on just on the family structure on what they go through. All I can say is. Don't give them money. Go to Burger King. I keep picking on Burger King. I might, I might probably want Burger King, but Oh, I see. It sounds good right now. It does. That old school chicken sandwich. Right, right. And it's so gross when you think about it, but you just want one bite once in a while. Just one bite. Just give me one bite. That's that, that's that double meat surge you was talking about, right? Exactly. Exactly. Right? And so it's just, you know, buying that person a meal, right? And meeting them where they're, where they're at. But for families that are out there that are struggling, make sure you're seeing a therapist yourself. Make sure the children in the family are seeing a therapist themselves. Connecting with resources like Al Anon and GRASP. These organizations will help you work through. And in the event your child passes or your loved one passes away, There's members in those organizations that have come into that same thing, right? So they will be able to provide a resource to you and support and I always think about like my really good friend Amy Who's our peer support? Her parents divorced as a result of her of her drug use and her mom even moved to Florida to get away from her You know, so when you're thinking about, um, I don't judge or shame any family member when they say is enough and is enough and close that door. The only thing I say is if you're driving them to a treatment center, just be silent. Don't belittle them, okay? It is a lot, and I know it's taxing on you, and a lot to ask of you to take them to a treatment center, but just don't belittle them. Just say, I'm glad you're going today, bud. Alright, I'll be waiting for you when you get out. You know, even though you just, you're tired of it yourself, and you want them to get better, driving them to treatment is them getting better. So, you know, because we hear this all the time from our patients. Yeah, so and so took me. I had to hear this, this and this and this because we're wondering why would they get into the clinic? They're so riled up and it's because what they have to deal with, you know, and they know that's their fault, but it's still not something like again, seek therapy so you can find other ways to channel that energy. And so that way that person can focus on themselves while they're in, while they're in treatment. And, and, and, you know, that holistic approach, you know, kind of taking a look at the, the, the entire patient, not only outside of the addiction, but also the psychology associated with it, for both the person affected as well as the family, you know, that is, that is entirely the way that we come out of this, right? Like we, we, we've created this issue. Wholly, a lot of it has to do with some of the, you know, pharmaceutical companies that have already been litigated, so we don't even have to debate that anymore. Right, but we need to move forward, and this is the avenue forward for that. Yeah, it is, it is. If anyone wants to help with some of the efforts, I know you mentioned initially, some of it is financial, with keeping some of these programs sustainable. If somebody, is interested in, either monetarily helping or helping in any other way, what is the best way that they can help CMS? And what's the best way that they can reach out? They can either, you can call myself. That's 414 510 2573. You can text me, you can email me, and that's just amanda. deleon, so my first and last name, at CMS gives hope dot com. And I will lead you to the right place that you can make that donation. Um, that you can help out whether or it's just, Hey, I hear you doing these pop ups. What do you guys need help at these pop ups? Can I bring the sandwiches on these Monday pop ups where you guys are going in the communities? Can I bring chips or Can I just be there to provide prayer for somebody who wants prayer? Because again, it's that holistic approach. Prayer doesn't work for everybody, neither does, you know, medications for opioid use disorder. Meeting that person where they're at and giving them the best quality of care possible, bringing all those resources to them. Thank you so much, I appreciate it. I'm definitely gonna be reaching out to you and see how I can further help with any of the efforts that you guys are doing. Please continue to do amazing things in the community. We appreciate everything that you're doing. Uh, and thank you so much for taking your day off here and talking to me. I appreciate it. No, I appreciate you asking me to be a part of this, Dr. Ford. I think we need more physicians like you in the EDs that understand it and that will say, okay, what can I do to help you? And doing things like this, thinking outside the box. Using your, your power, your status to say, Hey, this is what I'm putting out there. Just like jelly roll. I loved it. When jelly roll did that, I was like, use your power in your status to get the word out. I freaking love it. Shout out jelly roll. All right. Well, I appreciate you so much. Thank you so much. You're welcome. Thank you So that's it. I want to thank Amanda DeLeon for coming out and talking with us, sharing some of that valuable information on opioid use disorder and the services that are available in the state of Wisconsin, as well as in Milwaukee County. I want to thank you for listening. Join us next time where we'll have another special guest and cover more healthcare topics that affect the Milwaukee County area, as well as throughout the state of Wisconsin. Take care of yourselves, take care of each other, and if you need me, come and see me.