Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (21 page)

“I took all those…” Marilyn said, gesturing toward me.

“All these,” I said surveying the mountain of pill bottles.

“No,” she said and gestured again. “Well, no, but yes. Those.” She pointed at the aspirin bottle.

“How many?” Alisa asked.

Marilyn turned a little, shifting her gaze to Alisa. She looked very surprised to see her there. “I don't know.”

I dumped the few remaining aspirin pills out into my hand. “You mean the aspirin? You took all this aspirin?”

Marilyn looked at me blankly. “I don't know,” she said. “I think I did last night or maybe this morning but I'm not sure.” She gazed at me with an expression of absolute bewilderment. “I think I wanted to kill myself.”

“Last night?”

“I think so. No, it was today.” She grabbed my arm. “Don't tell my husband.”

“Where's your husband?”

“He's at work.” She looked away. “He doesn't know.”

“About the aspirin?”

Marilyn stared at the wall for a moment and then back at me. “What about the aspirin?”

“She's taken more than just aspirin,” Alisa said.

“Ma'am,” I said to her, “do you take all these pills?”

She looked at the pile of medicine. “I just take them like I'm 'spose to.”

“All of them?” I asked. I knew the answer. I even recognized the name of the doctor who had prescribed them.

My patient nodded, a good girl. “Just like Dr. Daiquiri says.”

Dr. Daiquiri. Good old Dr. Daiquiri, AKA Dr. Feelgood, the “Physician with a Prescription,” a prescription for any problem you might have. I saw Dr. Daiquiri's patients almost every day. They were migraine patients or chronic back-pain patients or professional insomniacs. Dr. Daiquiri would send them to the ER for a pain shot when their pain had become so severe that the thousands of pills he prescribed weren't enough. The trouble was that many had been coming in once or twice a week for years. They had received so many intramuscular injections their buttocks had scarred to wood. In between shots they took pills that Dr. Daiquiri would prescribe. Pain pills, diet pills, antianxiety pills. Not to discount cases of very real pain and anxiety, but after so many years of this kind of treatment most of these patients had acquired a new problem to go with their pain. They had become addicts—addicted to prescription drugs. And like any other kind of addict, they had become consumed by their addiction.

So here we were, “weak and dizzy.” My patient with her purse full of Dr. Daiquiri pills had turned out to be an overdose. I stood stating at the aspirin bottle. Aspirin overdoses are a bitch to treat. This “harmless” little pill can have deadly effects. Aspirin disrupts the body's acid-base balance; whole organs, kidneys, liver and brain can just shut down forever, depending on the amount ingested. Patients can seize, develop heart arrhythmias; in essence crash and burn at the blink of an eye.

I held up the bottle. “How many of these did you take?”

She tried to focus on the bottle but, after squinting for a moment, gave up and closed her eyes. “Ten or twelve, I think.”

I was relieved. This may not be as bad as I thought.

“How long ago did you take them?”

“I think two days ago.” She still had her eyes closed. “No, I mean two hours ago…”

Great, I thought. That's a lot of help.

An acute ingestion, a suicide attempt. Alisa looked at me and said, “The usual?”

I pursed my lips and nodded. “Honey, we're going to have to put a big tube down your nose and suck those aspirins out.”

Pumping someone's stomach, a traditional ER chore. It's usually associated with the “suicide gesture,” the “cry for help” that people make when their life goes wrong. Often this can be a very manipulative call for help. ER people look upon these suicide gestures so cynically that nurses frequently threaten to hold classes entitled “Suicide, How to Do It Right.”

I stopped myself at the foot of her bed and asked, “What's going on? Why did you do this?”

Marilyn glanced up at me. “I…” she stuttered. “I don't know. I don't know anything.” She put her face in her hands and started sobbing. “I don't even recognize myself in the mirror.”

I was trying to get a blood gas when Alisa put her head in and crooked her finger at me. “Husband's outside,” she told me.

“What does he have to say?” I asked.

“Oh, he's not talking to just
a nurse
.” As I walked out to the waiting room, I was mentally shaking my head. An aspirin overdose, strung out on prescription medication, presents as “weak and dizzy.” Doesn't it figure? In the ER even the unexpected is unpredictable. I paused at the triage desk wondering who could predict from one minute to the next. You start off thinking you know where you are—I looked around the waiting room for the husband—and you end up…well…here.

The woman's husband looked just as expensive as she did, only nothing about him looked unstrung. He was pacing, and when he saw me he stepped over and examined me with a critical eye. I winced at what I must look like, a sleep-deprived doctor wearing a once white coat, now splattered with blood and Betadine.

“
It's those pills,”
he said fiercely before I could say a word.

I spread my hands. “Has she ever taken an overdose before?”

“Overdose?” he asked sharply.

“Aspirin. I think. I'm not sure; she's really not making much sense.”

“Aspirin,” he said in a kind of wonder. “Well, she's taken nearly everything else.”

“All prescriptions?”

“Dr. Daiquiri,” he said shortly. “She's been seeing him for the last year.” He looked away. “She was trying to quit drinking,” he said.

I shuddered. A patient and a doctor meant for each other.

“She stopped drinking when she started seeing Dr. Daiquiri—I told her if she didn't, our marriage was finished. He put her on all these pills. Things are even worse now than before.” The husband looked at me to see if I knew what he meant. “This life is hell,” he said shortly. Then, “I would like to see her now.” He was not a man to be contradicted.

As we walked back, Alisa, carrying the overdose paraphernalia, stopped me in the hallway and said, “You're not going to believe this…”

I grimaced. “What now?”

She pointed with her chin. “Trauma room,” she said, “a live one.”

In the trauma room Benny and his partner, two city paramedics, were transferring a disheveled-looking young guy in a wet jogging suit from the paramedics' gurney to an ER cart.

“Someone called the police,” Benny told us. “He was down in the middle of the road when we found him.” Benny cocked his head meaningfully. “He was taking the
occasional
breath; really, really whacked out. We got an IV in him and gave him some Narcan, and”—Benny raised his hands in benediction— “it was a miracle.”

Narcan, a drug that reverses the effects of narcotics, works almost instantaneously. An overdose patient can go from no respiration, no breathing at all, to fully alert and awake (and generally pissed off) in less than thirty seconds.

The question here was, what kind of narcotic?

“Track marks?” I asked Benny.

The patient seemed to perk up a bit. He looked around at me and said, “I don't shoot drugs.” Speech still slurred, I noted.

“No, no. We know that, tiger,” Benny said. He handed me a plastic bag that contained some bottles, prescription bottles. Several. I pulled one out and started laughing. Pathetic, pathetic.

It was a bottle of vicodin. Dispensed: a hundred pills. Doctor: Dr. Daiquiri. Date dispensed: today.

The bottle was empty.

Two Dr. Daiquiri patients in one day, I thought sourly as I stomped back down the hall. And one an aspirin overdose no less. Back in the acute room my overdose lady was lying there in all the glory of an ER washout. She had an enormous lavacuator tube sprouting from her nose and there was charcoal everywhere. Charcoal is given as a sort of generic absorbant: it will bind many toxins and cause them to pass out of the gut harmlessly. It is also black and syrupy and it gets all over everything. Marilyn had already vomited some back up, not unusual for the stuff. It was all down the front of her hospital gown, matted in her hair, on the sheets, on the floor. Beside her sat her immaculate-looking husband. He was leaning back, arms folded, just staring at his wife as if he didn't recognize her, which, considering how she looked, was probably not a bad thing.

I thought she was asleep, but she opened her eyes when I walked up to the bed.

“What's the matter with me?” she asked.

“You take too many pills,” I told her.

“But my doctor prescribes them.”

“I know,” I said. “It doesn't matter.”

She started crying, great tears tinted gray with mascara. “I tried to hurt myself,” she said sobbing, shoulders shaking. “But I don't want to die. It's not that. It's just that I don't want to be alive.”

“Have you thought about a drug treatment program?” I asked her gently.

She looked up at me, too shocked to keep crying. “What do you mean? What are you saying?” she sputtered. “I'm not some kind of,” she spit it out, “
drug addict.”

The husband signaled me for another talk outside the room. He stood in the hallway, arms folded, glaring angrily toward the nurses' station. “All she does anymore is take those pills. I've tried to get her to see a real doctor, a psychiatrist, anybody, but that
quack
has her strung out on so many pills she doesn't have any idea what's she's doing. She lives for those damn pills.” He took a deep breath and then asked the obvious. “Why don't they prosecute that man?”

I shook my head. Dr. Daiquiri was one very smart guy. He knew what he could prescribe and how to do it so that he stayed on this side of the law. And he knew how to defend himself. He had threatened several doctors with legal action after they complained to the hospital administrators that he was prescribing too many narcotics. He was very slick.

But I was sure that there was more to this story than just Dr. Daiquiri.

“And you?” I said, looking at him.

He looked away. “I'm moving out,” he said. “I want a divorce.” He cleared his throat. “That's why she's doing this.” He looked back down at me, frowning deeply. “I can't take this life. I can't take all the pills. She can let them ruin
her
life, but I'm not going to let them ruin mine.”

I could see his wife from where we were standing. She was gazing off into the distance, one hand on her chest, clutching at her hospital gown. The hand was twitching, trembling, and then it scraped, claw-like across her chest. Her head was bent back and the twitching extended up her arms and shoulders. It took another heartbeat before I realized what was happening. “She's seizing,” I shouted.

I rushed to the head of the bed. My first thought was: Good God, what's next? I looked down at her face and as I did I saw the charcoal bubbling from her mouth.
She's aspirating,
I told myself in horror. She was vomiting up some of the charcoal with the seizure. Now she would breathe it down her trachea, into her lungs. She probably was doing so right now. This was a disaster, perhaps a deadly disaster.

She's aspirated, you fool,
I shouted to myself.
Why didn't you see this was coming?
One half of me stood there frozen, hands to my face, horrified. The other half, though, the professional half, smoothly took over. I hit the intercom button.
“I need some help in here and call Respiratory.”
Then I broke the plastic lock off the intubation cabinet and grabbed at the equipment there. The laryngoscope came first, a flat metal blade with a light attached to a large handle, and an endotracheal tube—ET tube—which goes down through the larynx into the trachea, so that we can breathe for the patient. You don't always need to intubate seizure patients; it's rare for a seizure to last long enough to cause a significant lack of oxygen. But this woman had a gut full of charcoal. She was only going to aspirate and aspirate more. I had to protect her airway, protect her lungs from more charcoal.

On the outside, my professional half smoothly assembled the intubation equipment. The horrified half hadn't disappeared, though. Inside I was seething, arguing back and forth with myself.

If I had known she was going to aspirate, I should have intubated her before I gave her the charcoal.

Still, how many overdose patients had I seen who were as compromised as Marilyn but had never seized?

Hundreds.

Charcoal-stained mucus bubbled up through Marilyn's nose. “Set up suction,” I told the respiratory therapist who had just arrived. The room was beginning to fill with people.

I tried to open the patient's mouth but couldn't. The seizure had clamped it shut tight. We needed to stop the seizure before I could even try to intubate her.

“We need Valium over here,” I told Alisa. The respiratory therapist got the Ambu bag ready and was fumbling with the suction. Pam, the other nurse, put the pulse oximeter on the patient's finger. This measures the amount of oxygen in the blood: 96–100 percent is normal. Anything below 90 is not good, below 80 is very bad. Marilyn's reading was 90 percent.

Alisa was back with a syringe and some Valium. She drew up 5 mg, injected it and flushed the line. We all stood watching. Nothing. Arms and legs jerking. Jaw clamped tight. Marilyn was still seizing. Charcoal still bubbled through her nose.

Her pulse oxymetry reading: 87 percent.

“More Valium,” I told Alisa, who drew up the other 5 mg from the vial.

She injected it. We all stared down at the patient. She had stopped being Marilyn. She was now the enemy: the patient gone bad.

Nothing. Still seizing. Jaw clamped shut.

85 percent.

“What now?” Alisa asked. Clearly Valium was not going to stop the seizure.

84 percent. 83 percent.

I had a choice. I could try to go through the nose with the tube, pass it down into the larynx blindly and see if I could get the tube into the trachea (not easy). Or I could paralyze her, and when she stopped seizing do the somewhat easier standard intubation.

Which one? Either or. Decide now.

83 percent. 82.

“Get the sux,” I told Alisa. “Sux” is short for succinylcholine, a drug that blocks all muscular activity. It produces total paralysis, making it easier to intubate, that is, get the tube down into the trachea. However, if I couldn't get her intubated, she wouldn't be able to breathe on her own. I would be stuck, or rather Marilyn would be stuck. Paralyzed, without an airway, about to die.