How to Deal with Problems
This is a chapter from Ecstasy Reconsidered
by Chris Jones, Teacher of Critical Care Courses for Nurses, Edge Hill
University College, Liverpool.
This chapter explains the medical nature of deaths and problems
caused by ecstasy, particularly overheating.
There are help sections on different levels, from the ordinary person to
hospital staff. The first explains what to do if you are out with friends
and one gets ill. It tells how you can help someone who has had a fit, or
collapses. The next is for those trained in first aid and paramedics. Last,
there is a section aimed at staff working in hospital emergency units.
A section for night club owners shows how they can provide support and how
to handle casualties.
Is it really ecstasy?
There have been many well publicised cases of young and previously healthy
experiencing some very ugly reactions to tablets containing MDMA (ecstasy).
Some others may have experienced adverse reactions to tablets sold as 'ecstasy'
when in fact they contain substances other than MDMA. The reactions to ecstasy
in this discussion will be confined to those situations where the person
has bought genuine ecstasy, and MDMA will be considered as synonymous with
ecstasy and E. These reactions to ecstasy can range from panic and the fear
of dying, to actually dying in the most depressing circumstances.
The following is an attempt to describe what happens to people who react
badly to ecstasy and what current thinking is to prevent and to treat E
It is a cliche to repeat this sentiment, yet it remains a cliche which
holds a lot of truth: if one wants to avoid the risks associated with ecstasy
or any other type of drug then the best way is to avoid taking it. Nobody
dies an ecstasy death without taking ecstasy.
That said, deaths associated with the use of E are relatively rare, compared
to the number of doses which are thought to be taken. And compared with
say motor cycling or even glue sniffing the numbers of fatalities are very
But that should not obscure the fact that ecstasy related deaths are very
grim. The problems associated with E result from overheating (hyperthermia).
This does not sound so bad. The problem is that the overheating in a serious
E event is so severe that even experienced and case hardened Emergency and
Intensive Care workers claim never to have never seen temperatures so high
(41-42oC). This level of heat produces a cascade of other problems including
unstoppable bleeding due to disturbances in the clotting system, even where
unlimited blood transfusions are available, liver and kidney failure and
This of course is the absolute worst case scenario which is thankfully relatively
rare. Nevertheless its rarity does not detract from its tragedy.
So what causes this sequence of events to commence? Can it be prevented?
And what does one do if a friend looks ill? What is the role of the club
paramedic? What is one to look out for? What equipment ought night clubs
to have at hand?
Currently the leading theory is that the deaths associated with E are
a form of drug induced heat stroke. This theory has a number of appealing
features including the following - E alters the body's thermometer and inclines
its user to warm up the core body temperature particularly where the external
ambient temperature is high. It is also said to lower temperature if the
external temperature is low. A warm temperature seems to enhance the E experience.
The overheating effect of ecstasy is exacerbated by the following factors:
* E users are thought to dance well beyond the point of which a "normal"
person would tire and sit down.
* DJ's play seamless sequences of records which keep dancers active, and
therefore producing more heat, over long periods of time.
* The club atmosphere is hot and humid. The evaporation of sweat is an essential
body defence mechanism to prevent overheating.
Beyond a certain level of ambient humidity skin stops evaporating sweat
- you can't unload water as efficiently into an atmosphere which is already
The result of this hyperthermia is that blood starts to clot or coagulate
over a widespread or disseminated area of the circulatory system. Elements
in blood which are normally there to block holes are activated. The blood
coagulation process uses the blood's elements involved in clotting (platelets,
fibrinogen and clotting factors) faster than they can be replaced. This
leads to an absolute decline in the quantity of these elements. The result
of this decline mimics the result of anticoagulation; blood eventually refuses
to clot. Bruising takes place. Gums bleed. There is haemorrhage. With an
ecstasy death this process takes place very quickly. Hyperthermia leads
rapidly to Disseminated Intravascular Coagulation (DIC) and the victim bleeds
to death (in the most severe cases).
DIC is a complication of the hyperthermia. Hyperthermia is a complication
of the use of the drug and its circumstances of use.
This is a very convincing theory which makes a lot of sense. Before the
rave scene, ecstasy was in widespread use in the USA. It was responsible
for a number of fatal incidents. But they did not involve bleeding to death.
Most fatalities were not the type of death we are familiar with in the UK.
On the other hand, the heat stroke theory is just that - a theory. There
is very little empirical evidence to support it. No studies have been done
to demonstrate that the night clubs in which there has been a fatality were
excessively hot or damp. It has not been demonstrated that victims danced
more or less than on other occasions, or drank more or less than on other
In addition there is a heavy weight of literature suggesting that there
are other drugs of the stimulant type which can on occasion cause a syndrome
resembling heat stroke. Both amphetamine sulphate and cocaine have been
reported to do this even in circumstances where there has been no great
physical effort. And conversely, if the cause of these hyperthermic deaths
were due to physical activity and ambient temperature then one might expect
dancers at night clubs who had ingested cocaine or amphetamine to become
hyperthermic through a similar mechanism, but this does not appear to happen.
There are also non stimulant drugs which produce hyperthermic responses.
For example some drugs used in psychiatry, and in anaesthesia will produce
a fatal hyperthermic reaction on occasion. The point of this discourse is
to suggest caution. Maybe E related harm is due to the circumstances in
which E is taken; the night club or party environment. Circumstantial evidence
suggests this is so; these are the venues which usually produce the admission
A more recently reported set of problems seem to be emerging. For a subset
of people who are injured by ecstasy there appears to be another sequence
of events at play. These are people who, for an improperly understood reason,
lose some of the sodium (salt) in their blood. Maybe it is sweated out.
Maybe it is urinated out in higher than normal quantities. Maybe ecstasy
causes people to become thirsty and they dilute their sodium by drinking
too much water. For whatever reason, they lose sodium. Technically, this
is called hyponatraemia.
Sodium has the remarkable quality of holding water in the body's veins and
arteries. Without it we tend to lose water into the fabric of our body's
tissues. We swell. This does not present so much of a problem for most tissues
but it presents the brain with real difficulties. The brain, encased as
it is by skull, cannot swell a lot. It becomes compressed and puts pressure
on the brain stem which controls heart and breathing functions. This can
be fatal. 'Isotonic' drinks, unlike pure water, will help replace some minerals
like sodium and preserve the balance of fluids in circulation.
So what do I do if I am out and my friend becomes ill?
The first thing to say in that most of the untoward effects of taking
an E will be self limiting. A sensation of heat, a sense of the heart going
faster, nausea, teeth clenching and visual disturbance may all be regarded
as the 'normal' effects of a dose of ecstasy. Not everyone who has taken
a tablet will like these effects. Many people will feel they have started
something they cannot control and will feel fearful that they cannot stop
themselves being carried along by the experience. They will be aware of
where they are and what day it is, but they will be anxious and fearful.
Get them out of the noise and the bright lights. Stay with them. Be reassuring.
Give them a drink to sip but be careful they do not attempt to drown their
anxiety in water. If possible try and get them to drink an 'isotonic' or
sports type drink. Tell them they will be all right and take them home.
Don't leave them alone, just in case they become worse.
Things to watch out for:
* Disorientation in time and place. They can't say where they are or what
day it is.
* Drowsiness that comes to be unresponsive to commands like "open your
eyes" or "squeeze my hand".
* Anything which looks like fitting.
* Breathlessness or difficulty breathing.
* They feel abnormally hot to your touch even though they have been in a
cool environment for some time.
At this point it is time for professional advice and a trip to hospital.
You will be treated in confidence and with respect by the medical and nursing
Collapse and unconsciousness
You are dancing with your friend on the dance floor, they look rather
sweaty and out of it, their legs look heavy and clumsy. They fall and appear
to faint. They may appear to have a fit.
Do not disregard this turn of events. Do not think they will be all right
if they get up and 'dance it off'. Hyperthermia first affects the central
nervous system and can cause it to shut down. This could be the prelude
to some very serious events and needs a prompt response.
If you are at a night club the security personnel should be alerted and
the club paramedic should be summoned (if there is one). A quiet and subdued
recovery area should be available to take the person into.
Give as much information as you can about your friend's medical history.
Are they epileptic? Are they diabetic? What have they taken? In what combinations?
Make a note of the response of the club staff. If they simply dump your
friend out of the club and into the street then this should not be tolerated
by the community and should carry consequences for the organisers.
What implications should these casualties have for night club owners?
The organisers of a rave, a large dance event or a night club have special
In the current climate the balance between organising a relaxed and informal
dance event and preventing drug dealing and related problems by adequate
security is hard to achieve. A night club which has heavy security atmosphere
will find it hard to generate the underground atmosphere that clubbers seem
to find appealing.
That said, there are numerous codes of practice in circulation to assist
night club owners and dance event organisers to provide minimally decent
conditions for their clients. Particular attention is drawn in these documents
to the following headings:
* The prevention of overcrowding. This is obviously of crucial importance
in the control of the temperature but also the humidity of the night club
* The availability of drinking water. This should be regarded as a basic
requirement of decent management. Free water (or rather water as part of
the entrance costs) should be available for dancers on request. Chilled
soft drinks should also be available, particularly sports drinks which contain
* Air conditioning and ventilation. This will control temperature rises
in the night club and prevent overheating, which will contribute to the
comfort and safety of dancers.
* Provision of 'chill out' areas where people can sit and cool down in a
quieter and cooler environment
* Thought on the part of the DJ about giving dancers a rest periodically,
by placing breaks in the music or by slowing the tempo down intermittently.
* The provision of first aid or paramedic cover, particularly at large or
What should be the response of the paramedic?
The definition of what constitutes the term 'paramedic' is subject to
various interpretations. In this discussion the rather non technical definition
of someone formally trained in first aid (as a minimum) will be used.
For all the services designated to help promote safety in clubs the emphasis
should be on prevention of problems. If heat stroke is the cause of the
fatalities and overheating can be prevented then lives may well be saved
by some simple precautions.
Paramedics are in a position to assist in researching the problem of E related
problems - for instance in measuring the temperature and humidity in night
clubs. Club owners might consider the measurement of these parameters a
wise legal precaution in the event of them being accused of poor public
safety provision for their clients. Other priorities for the paramedic might
* Keeping notes on the types of problems which occur including the name
of the casualty, what formal observations are made (temperature, pulse,
level of consciousness etc.).
* Relating problems to the types of E which have been taken : are some "brands"
producing more problems than others?
For paramedics in nightclubs there are bound to be a huge range of problems
to deal with, mostly non E related, and the paramedics role is likely to
be very challenging.
* There will be cuts and sprains.
* There will be alcohol related problems; vomiting , passing out etc.
* There will be non E related drug problems, after all ecstasy is not the
only drug used by clubbers.
* There will be general medical conditions, asthma, epilepsy etc. that come
on in the club where there are high output smoke machines and stroboscopic
* There may be the fights with resulting levels of trauma.
* There may be the complex pathology of ecstasy toxicity.
The first essential piece of equipment required by a paramedic is formal
paramedic or first aid training by a recognised qualifying organisation
e.g. Red Cross or St. John's Ambulance. At large venues in particular, it
is simply not enough to have untrained personnel dealing with potential
problems of this order of complexity. Basic life support skills are essential.
Secondly they ought to be aware of drugs and drug related problems particularly
relating to hyperthermia, dehydration and anxiety states.
Considering that fatalities have been associated with overheating, a paramedic
facility ought to be equipped with somewhere to lie the casualty down, cold
water, maybe some sachets of mineral replacement powders available from
pharmacies, a fan or air conditioning device, an electric thermometer, a
collection of airways, an ice machine and a non contact artificial respiration
mask should be available. There should also be a telephone so that an ambulance
can be called if required. Any first aid facility should have enough room
to get a stretcher in and out if necessary.
Friends should be asked to reassure and sit with people whose problems amount
to little more than anxiety. Also to accompany the victim to hospital if
required. They can give an accurate history to medical staff and will be
aware of subtle alterations in the patients psychology.
Suggested approach for club paramedics
A person is brought to the paramedic:
* Is the person conscious? If No, ring ambulance.
* Is there a normal level of consciousness? (Do they know where they are
or what day it is?) If No, ring ambulance.
* Can you detect any physical problems? eg. Racing pulse (over 120/min over
five minutes of quiet and rest), high temperature, abnormal prolonged sweating
or breathlessness. If Yes, ring ambulance.
* Put in recovery position. Sit down, observe for levels of consciousness,
heart rate, temperature.
* Do not give anything by mouth rate, temperature.
* Keep off dance floor.
* Check pulse.
* Do not leave alone.
* Assess temperature.
* Remove excess clothing.
* Commence cooling - fan/water.
* Observe for unusual bruising/bleeding.
If the problems associated with E are due to overheating then the quicker
that heating can be controlled the fewer (theoretically) complications will
Removing hats, woollies, shoes and socks and commencing fanning and sponging
down ahead of the arrival of the ambulance might reduce body temperature
enough to prevent the worst of the problems.
Do not be tempted to give the victim large volumes to drink. Drinking pint
after pint of water can seriously damage the delicate balance of fluids
inside a person's body. The result of this can be catastrophic and itself
cause unconsciousness and fitting in the victim. Sipping a glass of cold
water over an hour will replace lost fluids, and a mineral rich replacement
sachet or isotonic sports drink should supplement salts.
If you have to call an ambulance
Get as accurate a story from a witness as possible. Send a friend of
the victim if you can ­p; the friend will have an idea about the type
of tablets taken and may still posses an example for analysis. This might
be extremely useful if a toxic batch has come on to the market.
Advice to staff working in emergency units
Many hospitals in city areas have now seen at least one example of an
related emergency and most units are now sensitive to this type of drug
This does not alter the fact however that an ecstasy casualty can produce
a confusing clinical picture and may exhibit odd and atypical signs and
symptoms. Frequently the patient is not in a position to "own up"
to taking drugs due to loss of consciousness and the best source of information
are friends who may have come in the ambulance. These friends are not likely
to be as forthcoming as they might otherwise be if they fear the response
of the accident and emergency staff.
Confidentiality, particularly with parents and police, and an open and non
judgmental attitude is not only the basis of an ethical approach to ecstasy
related problems, it is of vital clinical importance. The friends are your
best source of information if the casualty is unconscious. They must feel
confident in you. They must feel safe with you. There must be a relationship
Taking dance drugs is, after all, a mainstream activity for many thousands
of young people every week end. Victims are unlucky or maybe foolish (depending
on your point of view) rather than evil.
So what needs to be done?
Firstly the drug induced aspect of the problem needs to be recognised.
* What is the source of admission? Is it a night club, a concert, a party
(high suspicion), or is it somewhere quiet and unlikely to have a rave atmosphere
* What is the time of admission? Is it in the early hours of the morning
(high suspicion) or is it in the middle of the afternoon (low suspicion)?
* What day is the admission? Is it a weekend night (high suspicion) or the
midweek (low suspicion)?
* What does the patient appear like? Are the pupils dilated? Are they writhing
and twisted? Are they hot?
* What is the drug? Are they carrying any tablets or what do their friends
Formal observations may include temperature which may be elevated, pulse
which may be rapid and thready and blood pressure which may be low.
Central to controlling ecstasy related problems is thought to be the control
of core temperature and restoration of circulating volu