A Richmond ER doctor is warning about the dangers of inhaling nitrous oxide (N2O) after treating a 20-year-old woman who experienced hallucinations stemming from daily use of “whippits.”
According to a report published this month in the B.C. Medical Journal, Dr. Matthew Mo Kin Kwok — one of the report’s authors — treated a young Asian woman who came to emergency at Richmond Hospital because she was worried for her safety.
The woman was experiencing auditory and visual hallucinations, agitation and had issues walking, according to the report.
The high from whippits, which produces a dissociative state, typically lasts one to two minutes, according to the report.
As a result of her hallucinations, she was also concerned about an imaginary “transmitting” device in her throat, which she believed was making her legs weak and from which she heard voices telling her to kill herself.
N2O easily accessible
Commonly known as “laughing gas,” N2O is used in a medical setting for purposes such as anaesthesia or sedation.
It’s also commercially available in canisters known as whippits, which are used as a foaming agent in whipped cream dispensers. Whippets can be purchased over-the-counter or online regardless of age, medical history or intended use.
The N2O in over-the-counter whippits is the exact same as what’s used for medicinal purposes.
The woman had no history of psychiatric or medical illness, according to the report, had stable vital signs and showed no sign of head trauma. Other medical tests came back normal.
However, said the report, she told doctors that she inhaled nitrous oxide on a daily basis.
“She had increased her use recently and was inhaling gas from approximately 100 whippits per day,” reads the report.
The patient told doctors she bought the canisters legally using a shopping app and showed the physician the website she used when making the purchases. She did not report any other prescription or recreational drug use.
“A psychiatrist, a neurologist and an addiction medicine physician assessed the patient in consultation and agreed that she was psychotic as a result of N2O use,” reads the report.
And according to the report, the authors found that a package of 100 canisters could be purchased online for less than $100, or $1 per canister.
Lack of reporting a concern
According to the report, there were multiple barriers when it came to reporting the woman’s case.
First, it was difficult to determine which authority to report the case to. For example, if the use of the chemical was medicinal, health care providers would need to report to the Canada Vigilance Program.
But if the chemical comes from a product used for whipped cream, the case should be reported to Health Canada Consumer Products and Cosmetics.
But the response from those authorities was also an issue.
“In response to our report, a Health Canada representative explained that consumer products and cosmetics would document the misuse but only take further action if the (nitrous oxide) canister had faults or hazards regarding its intended use, which is making whipped cream,” reads the report.
The report’s authors were “surprised” to learn that no cases of nitrous oxide misuse had been reported to Health Canada and only one case of substance abuse was reported to the Canada Vigilance Program.
The authors also contacted the B.C. Drug and Poison Information Centre, which informed them that the organization had received 14 calls about nitrous oxide toxicity from misuse of whippets or similar commercial products between 2015 and 2019.
“Since our investigation determined that Health Canada received only one report of N2O misuse in this period, many incidents appear to have gone unreported,” reads the report.
In 2017, the News reported how a 23-year-old Richmond man was almost paralyzed after overdosing on N2O, having bought the gas on WeChat.
At the height of his addiction, the man inhaled more than 1,000 eight-gram cartridges of nitrous oxide every day for two months.
He also said he experienced delusions, such as someone chasing him while he was driving or someone was going to hurt him.
According to Kwok’s report, Health Canada considers N2O to be an “unscheduled non-prescription professional use” product.
“This raises an important question,” reads the report. “If N2O used medicinally is deemed to require health care provider involvement, why is the purchase of N2O used commercially not restricted in any way given the potential impact on consumers?”
Some possible solutions to a lack of awareness around N2O toxicity and its possible serious effects, according to the report, are adding safeguards to minimize harm and encouraging intervention from authorities to prevent misuse.
In a release from Vancouver Coastal Health, Kwok also said both doctors and the public need to be more aware of the possible outcomes of inhaling whippits.
“When people present at the emergency department with unexplained neurological symptoms it’s important for clinicians to consider nitrous oxide as a possible cause,” said Kwok.
“It’s also important for users to know that using this product outside a supervised medical setting can cause serious health effects.”
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Researchers whose projections for the spread of the novel coronavirus have proven grimly accurate for the United States say the number of deaths in Canada could surge dramatically late this year, unless measures change.
The latest model from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington says Canada could see 16,214 deaths by Jan. 1. That number drops down to 12,053 fatalities if masks are universally worn by people across the country.
At least one expert has expressed doubt on the projections, however, saying they don’t take increased protections for vulnerable populations into account.
Since the coronavirus was first detected in Canada in January, 9,244 Canadians to date have died of complications from COVID-19, the disease caused by the virus.
Dr. Ali Mokdad, a member of the IHME’s senior management team and a professor of health metrics sciences, says the majority of the projected deaths will likely occur in December.
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“That’s when the weather will get much colder and align with what we see during a pneumonia season,” he said.
“We’re seeing the same pattern over and over between COVID-19 and pneumonia in every country in the southern hemisphere, and now that’s heading in our direction.”
While coronavirus cases have been surging across Canada over the past week, with over 1,000 new cases being reported daily, deaths have stayed relatively flat for months. The country hasn’t reported over 20 daily deaths since July 3, and has seen fewer than 10 nearly every day in September.
But Mokdad says that could change if cases don’t start trending downward. He pointed to the U.S., where deaths began spiking over 1,000 a day roughly a month after cases surged this past summer.
“We saw this in other countries too: when you start opening schools and businesses, who’s more likely to go there? The younger generation,” he said.
“But they don’t live in a bubble. So they’ll start interacting with their parents and grandparents, and that’s when you’ll start to see a spike in mortality.”
According to the IHME’s modelling, the majority of new deaths in Canada will be seen in Ontario and Quebec, which Mokdad says is based on population size. Ontario could rise from over 2,800 deaths now to 5,773 by Jan. 1 if measures stay the same. Quebec, which has seen more than 5,800 fatalities to date, is projected to jump to 9,825.
The death tolls in British Columbia and Alberta, the other two provinces currently driving up the national case numbers, are projected to remain relatively flat through the winter, according to the modelling.
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Stephen Hoption Cann, an infectious disease expert at the University of British Columbia, thinks the IHME’s model doesn’t reflect protections now in place for vulnerable people like the elderly, which could help limit any new deaths.
“We’re seeing more caution when it comes to long-term care residents, immune compromised people, where we’re limiting their interactions and keeping them protected,” he said.
That, coupled with the lower mortality rate among younger patients, makes Hoption Cann think the fall and winter could be less deadly than anticipated.
“So many people I talk to now who are in that older group, they simply don’t want to take the risk of opening themselves up to more interaction and the like,” he said. “So if that continues, we’ll be in a better place.”
What can bring the numbers down?
The IHME model has been considered a tentpole for data mappers during the pandemic and has been frequently cited by the White House Coronavirus Task Force. It has also largely aligned with projections from the country’s Centres for Disease Control and Prevention.
After projecting earlier this year that the U.S. would surpass 200,000 deaths in September — which proved to be accurate — the model now estimates there could be up to 371,509 lives lost by Jan. 1.
Modelling released by the Public Health Agency of Canada on Tuesday only goes as far as early October, when it predicts Canada’s death toll will reach up to 9,300. However, it does suggest cases could see a major upswing through October into early November if measures aren’t tightened, potentially reaching up to 5,000 new cases daily.
While Hoption Cann says that upswing could lead to a surge in deaths a month later, he again said the majority of deaths projected by the IHME can be avoided.
“It all depends on what kind of further measures the provinces put in place to tamp down this rise in cases we’re seeing,” he said. “I don’t think we’ll see widespread business closures, but they’ll likely just ask people to kick what they’re already doing into a higher gear.”
Canada’s chief medical officer Dr. Theresa Tam said this week that the current surge can be countered if people “redouble their efforts with personal precautions.” In his address to the nation Wednesday, Prime Minister Justin Trudeau echoed that plea and said he’s confident Canadians can “bend the curve” together again.
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Mokdad agreed, saying widespread mask-wearing could help control the spread of COVID-19.
“If 95 per cent of people in Canada wear a mask … you can avoid many of the cases and deaths that we are projecting,” he said.
“We can’t avoid new cases and deaths entirely, because we have schools and businesses open and the weather is getting colder. But masks can make a difference.”
Mokdad, who is watching the Canadian response to the pandemic from the U.S., says he admires the steps Ottawa has taken to help flatten the curve — particularly compared to the conflicting messages coming from Washington, D.C.
“(Canada) went by the book,” he said. “The lockdown early on, the testing, all was by the book. But the most important part that was done right was the cohesive national message given to the public.
“And Canadians have done a better job than Americans at following those messages.”
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With 20 years of experience working at the CDC before joining the IHME, he says it’s “frustrating” to watch the institution struggle to deliver a clear message to Americans.
“We have taught other countries how to handle situations like this one,” he said. “So when you’re watching people all over the world dealing with the pandemic, and you know that you taught them how to do it, and they have done what you taught them — why the people here are not doing the same thing here, and not being allowed to in some ways, it’s very frustrating.
“I’m a very optimistic guy. If we get our act together (in the United States), if we are united but not divided and let science dictate policies, then we can do what you guys have done.”
© 2020 Global News, a division of Corus Entertainment Inc.
2 students test positive for COVID-19 in North York in 1st Toronto school outbreak – CBC.ca
Two students have tested positive for COVID-19 at a North York elementary school, marking the city’s first school-based outbreak.
Two class cohorts at Glen Park Public School— one with 17 children and the other with 18 — were sent home to self-isolate for 14 days, said Dr. Eileen de Villa, the city’s medical officer of health, at a news conference Friday afternoon.
“All steps have been followed as expected in a situation of this nature,” she said.
Parents in the school community were notified in writing, she said, adding that protocols at the school continue to be strictly followed, including masking requirements and enhanced cleaning measures.
“One of the realities of living in a world with COVID-19 is that there will be cases in schools,” de Villa said.
“Today’s news is expected. I expect there will be similar announcements in future and you can be confident the steps developed to manage the situation and reduce the risk of spread will be followed,” she added.
This occurrence qualifies as an outbreak, de Villa said, because it fits the definition of at least two cases within a 14-day period with one at least linked to the school.
And she said declaring it as an outbreak means a swift response.
“That’s really what the point of declaring the outbreak is,” she said. “[It’s] to make sure that you’re marshalling all the resources necessary, that the appropriate attention is paid to the circumstances so that we can manage the risk and reduce transmission.”
The Toronto District School Board posted on Twitter that it had updated its mask guidelines as a result of rising cases in the city, as well as due to confirmed cases in their community.
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Toronto’s top public health official also ordered four hospitality businesses to close on Friday after it was discovered they weren’t following the rules.
The businesses were flouting public health protocols and evading investigators, de Villa said. She added that some were pressuring staff to work even when sick.
The businesses, whose names she did not share because the operation to shut them down was not yet complete, will be allowed to reopen once the city is satisfied they’ll follow the rules.
“In these circumstances, the action taken is the right action to protect your health. The names of the affected businesses and their locations will be released to media once the process of serving the orders is completed,” she said.
While the reasons for the closures were “distinct” to each business, de Villa said Toronto Public Health found that “many people” were connected to more than one of the four businesses.
De Villa said some people who were infected with COVID-19 worked at more than one of the four locations.
In one instance, a business was also found to serve food buffet-style, which is prohibited by provincial regulations.
She added that the operators of the locations were so uncooperative that the city’s investigation efforts were “significantly impeded.”
Businesses who have complied with the city’s investigations, she said, are commended for stepping up.
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