17 September 1996

 "Ingestion," it says on the triage sheet.  Attached to the chart is a small zip lock bag holding dozens of yellow capsules which are labeled individually as "anafranil."  Interesting.  Scan the vitals -- they're okay, which means that I have time to go play in the PDR to try to find out just what the hell anafranil is. 

Paydirt.  The index tells me I can read all about it on page 893.  Several seconds later my upper year looks over at me as I quietly mutter, "oh-oh."  I spin the book around to show him, and he grimaces briefly and starts to flip through a toxicology book.

It turns out that anafranil the trade-name of a tricyclic antidepressant.  Bummer.  You can get way dead from TCA's.  The older antidepressants, unlike prozac or zoloft, are just incredibly dangerous in overdose.

There's a little monster hunched over in the back of my mind cackling in demented glee and rubbing it's hands together eagerly.  "This could be fun," it thinks.

Alright.  I pick up the chart and wander into the room.


It is one-thirty in the morning, and I'm up on the north end of the department.  I'm still kinda sweat-damp from multiple attempts at reducing a dislocated shoulder.  At some point in our efforts I ditched the scrub-shirt I was wearing over my turtleneck 'cause it was too hot, so basically I now look exactly like any schmoe off the street except maybe for the stethoscope snaked over my shoulders.

There on the bed is a young woman half-draped with a sheet, arms gripping both of the rails.  She's wearing loose white cotton panties, and is evidently none too concerned about who knows it. 

"Um - weren't you here a little bit earlier this evening?"

She looks at me angrily.  "Yeah, and the goddamned doctor wrote me a prescription for some pills and sent me home - I mean at nine o'clock at night.  Where the fuck was I supposed to get the prescription filled?"

"The Giant Eagle, down on Cedar.  It's open 'til ten."

"No it's not."

"It most certainly is."

"No it's not."

Way to go Marcus, says the little voice in the back of my head.  Play "is too/is not" with a patient who just took tricyclics.  Brilliant.

"Oh well.  So you're back.  What happened?"

"I just wanted to get some sleep."


"So I took three or four hundred milligrams of anafranil."

Inwardly I heave a sigh of relief.  It is almost certainly not a toxic dose.   With a fair bit of patient prodding, I'm able to gather that she also took eleven half-milligram klonopins, sixty twenty-milligram ritalins and eleven belladonna pills.

"Where did you manage to get your hands on belladonna pills?"

"Drug store."

"What on earth are they for?"

She looks back at me and gives me an eloquent shrug that says you're the doctor, asshole"I just want to get some sleep."

"Not tonight," I think to myself.


I step out of the room to present to the upper year.  I run through my story and then start to tell him what I want to do for her and what studies I want to get.  "Do you think we need to get an EKG?" I ask.

"Yeah, probably."

"With that low a dose?"

"What if she took more than she admits?"


Oh, hell.  I am an idiot.  Rule number one is Patients Lie.  Always and anywhere, you must remember that rule.  Context is irrelevant.  I've been chanting it daily for three years, quoting it to my colleagues every chance I get.  It is perverse and cynical, but completely true nevertheless.  This is not to say that all patients lie all the time, by no means.  Generally speaking, folks honestly want to get better from whatever's ailing them, and will do everything they can to help you discover and treat the problem.  Still-- intentionally or not, there is a significant fraction of folks who either misrepresent or misrecall historical events that are crucial to your understanding of the problem.

So here I am, treating a patient who has a poly-drug ingestion in what is at the very least a suicidal gesture, and I'm crediting everything she says as gospel.  Bright move.


"Oh . . . oh yeah, she could be lying.  How about that.  Lessee - that means we need to send a urine tox screen, and I guess acetaminophen and aspirin levels as well."

"Good.  What else do we need to do for her?"

He speaks with an accent that is a rather interesting blend of Britain and Boston.  I reckon that women must find it intrinsically rather compelling, and find myself wondering ludicrously how I can get a gnarly accent to try out.

"Charcoal," I announce brightly, "she must have charcoal."



I go back into the room to explain to her that she must drink activated charcoal and sorbitol.  She refuses.

"I don't want it."

"I don't blame you.  It doesn't taste great, and it makes your teeth all nasty-looking until it washes away.  Still, it's very important that we get some into you to bind as much free drug as possible."

"I refuse."

Click.  She has just shifted gears, and now I must go down another pathway.

"Okay.  I want to be really clear about this, so I'm going to explain what we're doing and why.  You just took an intentional overdose of several drugs, at least one of which could quite possibly kill you.  Because of that, you are at least for the time being not legally competent to make decisions regarding your welfare.  I'm not trying to be a bastard, I'm just explaining the way things are."

"I may be the scum of the earth man, but I'm not a fucking idiot," she tells me.

"I don't believe you're the scum of the earth, and you are clearly way above average in intelligence.  That's why I'm explaining.  The bottom line is that you simply don't have a choice about what happens here - no choice whatsoever.  On the other hand, you have every choice about how it happens.  You are going to get fifty grams of activated charcoal.  You may drink it, or you may get it through a tube into your stomach.  You can have a couple of minutes to think about it."

She clearly anticipated this part of our therapeutic regimen, for she had announced to the triage nurse on arrival that she had some kind of mesh thingy in her nose which made passage of a naso-gastric tube completely forbidden.  She points this out to me again.  Fair enough. 

"Since you can't have the tube through your nose, I will pass it through your mouth.  It's not terribly comfortable.  If it were me, I think I'd rather try to drink the stuff."

"I won't drink it."


There are two nurses in the room with me, who have been setting up monitoring equipment and other assorted odds and ends while I was talking to her.  When I look up from the bed, one of them shoots me a grin from behind the patient and holds a lubricated tube before her.  The other has a cup of water, complete with bendy-straw.  No time like the present, I guess.  I grab gloves and accept the tube.

"Open up, please."

To my surprise, she does, and seconds later I have the tube in her stomach.  I tape it in place, being careful not to get any of her hair caught.

"You'd better restrain my hands," she says.

"Excuse me?"

"I have this problem - I tend to be very uncooperative, and I might just decide to pull this tube out."

"Well okay then.  We'll restrain you."


Twenty minutes later there's yelling from her room.

"Why are you yelling?"

"Because you seem to come running every time I do it.  Get these fucking restraints off of me."

"Not right now.  Why don't you see if you can't get some of that sleep you wanted?"

"Because I can't fucking sleep here with all you assholes running around."

"Okay."  I turn and leave.


An hour or so after that the nurse who's had the misfortune of handling most of this lady's care asks me sweetly if she can put the patient in leather restraints instead of the soft ones we used initially.

When I ask why, she tells me that the she has managed to remove them, and has also pulled out my lovely orogastric tube.  She has also been threatening violence. 


I walk back into the room to see her sitting on the end of the bed.  I just stand there for a moment, resting my chin in hand, looking at her.  She has dramatically hiked her gown up over her hips, and her legs are set wide, giving all of us a clear view of crotch covered by a wide expanse of white cotton.

"What the fuck do you want now?" she asks, head cocked.

"Actually, I kinda want to know why you pulled out the tube."

"I was sick of it.  I'm leaving."

"We've already been through this.  I can't let you leave - I just can't.  I'm sorry."

There are now two nurses and a security guard in the room.  They're starting to strap the heavy leather restraints around her wrists.

"Why are you restraining me?"

"Because you pose a threat to yourself, and more importantly to my staff, which is intolerable.  You have demonstrated this beyond any shadow of a doubt, so I'm going to restrain you so you can't hurt yourself or any of us."

"I'll just yell continuously if you put those leather restraints on me."

"I wish you wouldn't, but I really can't stop you."


I tell the team about her threat when I go back out to the nursing station.  One of the nurses responds stoically, "she'll get tired of it before we do."

So anyhow, after several more hours of theatrics and silliness, she gets sent up to the floor to serve out her nominal twelve hours on a heart monitor before being transferred over the care of our psychiatric staff.  Her bed passes before the nursing station on her way upstairs, and she's still in the leather restraints.  She manages to summon forth the energy to curse all of us apathetically as she passes. 

When I come in for conference the next day, I ask the toxicology fellow how she did.

"Well, she cleared medically, just as you expected."

"And then she went over to psych, right?  Guess I'm gonna have to find out when and where the hearing is, 'cause I'm the one who committed her.  Aw man- I hate going to those things; they're invariably in the middle of my day off . . . "

"No, I think you'll be okay on this one."

"What - she decided to convert to a voluntary stay?"

"Not exactly.  She sort of eloped."

"Oopsie.  Someone's gonna be in serious dutch for that.  They knew she was committed involuntarily.  Police looking for her?"


"Well there you have it.  More fun and games in the big city.  Onwards, eh?"