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 people
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 related problems.

Overheating
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 small.

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 death.

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?

Heat stroke
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 damp.

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 occasions.

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 to hospital.

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 staff.

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 difficulties.

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 or dance.
* 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 sodium.
* 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 remote events.

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 include:

* 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 light effects.
* 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 occur.

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 ecstasy
related emergency and most units are now sensitive to this type of drug emergency.

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 of trust.

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 (low suspicion)?
* 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 say?

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.