Work & Surreality

19 February 1996


I managed to get out of the morning's rads lecture in time to blitz over to morning rounds in the Emergency Department, which I try to get to whenever I can. I'm doing radiology this month, so I'm often able to make it several days in a row. I go partly to schmooze and see what's going down in the department at the moment, but also for the rounds themselves, which are almost always centered on an interesting case from the last twenty four hours or so.

Ari, one of our attendings, had originally meant to continue a talk from last week about penetrating trauma to the eye. After a sotto vocce comment from one of my colleagues though, I sort of persuaded him that it might be more fun to consider "the approach to the gorked-out individual found down in the field" instead.

Its not as silly a topic as you think, as taking care of that particular kind of patient tends to be rather an arcane blend of art and algorithm. There is a well-tested protocol, but you have to remember to integrate your own clinical impression into the picture or you can miss things, or maybe end up doing something that isn't necessary.

These patients can't tell you their stories, see - because they're gorked. You have to figure it out: figure it all out, and do it all by yourself. You have to watch that you don't succumb to the temptation to treat their perilously low blood sugar and then walk away congratulating yourself for being a gnarly clinician and all-around astute motherfucker. It's the kind of mistake you'll only make once though, because while you're sitting there writing a self-satisfied note in the chart, the patient will likely do something ungrateful like forget to breathe and then code and die on you because of the massive heroin overdose you missed.


After Ari was done with his talk I cruised out of the room we had co-opted for rounds to see that all four of the high acuity bays were occupied. I also saw that the folks in number one seemed to be having more than a little difficulty keeping their patient on the bed.

I walked over with an offer to help and soon found myself stretched bodily across the guy's legs, trying to keep his knees flat so he couldn't torque his entire body up and over the siderails. Not that he was deliberately fighting us; he was just rammy as hell: way wacked-out.

He was muttering something in a incoherent blend of Español and English about beating the living shit out of us, all the while writhing on the bed with the insane strength of the recently overdosed. He looked very much like he'd taken way too much PCP or maybe something cut with ketamine.

Joe was the nurse in charge, up at the head of the bed more or less supervising our efforts. He's a thick-set fellow with long hair and a wonderful biker's beard, and he was talking to the patient in calm soothing tones.

"There's one of you and six of us," he said gently, "If you actually manage to connect one of those fists with any of us, I personally guarantee it will be the last thing you ever do."

Joe is wonderful - he's a pure blast to work with and he misses absolutely nothing. He even lets me sneak outside with him sometimes and bum a cigarette in the middle of long, busy shifts. Occasional bon-mots like that only make it better: I started to giggle hysterically, only to catch one of the patients flailing knees in my midriff.

After two more people came in to hold the guy's arm still, one of the other nurses finally managed to get a working IV started. Half an hour later, after getting incremental doses of two different relatives of valium summing up to, well - quite a bit, the patient actually began to calm down.

Seeing that things were more or less under control for the moment, the attending passed the dude's chart off to one of my classmates, and I sauntered out of the room looking for trouble.


In room three was Zuli, one of our Internal Medicine interns, looking rather tiny next to the woman she was trying to get started with. It was just her and Josette, and both of them are small women. The woman on the bed was decidedly not small. Not obese, but certainly big enough to be quite a handful. She was twitching her head back and forth crazily and writhing about like mad, apparently trying to snake her way off the end of the bed for the four foot drop to the hard linoleum floor.

I offered to help, not because it was entirely clear that they needed it (they didn't) but rather for the pleasure of being in a room with both of them at the same time.


I found myself thinking that the woman on the bed actually looked quite a bit like the guy I had just left to the tender ministrations of my classmate - not like they were relatives or anything, not with her pasty white against his rich brown, but they were acting very similarly indeed.

I also noticed that there was a rather noisy woman in the bay next to ours, just beginning to make the unmistakable coughing retch that is typical of folks who have just had an overdose of something like heroin or morphine reversed by our anti-opioid wonderdrug, narcan.

I looked up at Josette, who was in the midst of doing four different things simultaneously and wondered aloud, "Christ, what did they do, bring in a whole house full of 'em?"

From within a tangle of leads for the monitoring setup she looked directly back at me. "Yes. We've got four, Episcopal has six, Einstein has four or five, and I think they took a few to Hahnemann."

"Oh," I said stupidly.


It turned out that Ari's talk in rounds had been a piece of uncanny good timing. Four people were brought in to our E/D simultaneously, apparently all found in or around the same shooting gallery.

The story the cops gave us was that these people were all just kind of hanging out and doing their thing when they started hitting the floor for no obvious good reason. Apparently there was some new kind of shit for people to inject into their bodies out on the streets, and there was something very badly wrong with it. Oops.

Of course its not like the dealers really care that much if they kill off a couple of their customers, because there will always be more than enough folks queueing up to take their places. Caveat emptor, baby.


The woman we were working with had already gotten the standard dose of narcan but it hadn't really made any kind of perceptible difference. Looking her over carefully as we cut her clothes away (so we could make sure that we hadn't missed a good reason for the writhing, like maybe a bullet-hole) I noticed that she had a rather nasty looking skin infection where she shoots low into her external jugular vein. No track marks on her arms, and she was fairly well kempt: recently bathed, wearing clean clothes, hair neatly cut. A hobbyist, I surmised, rather than a pro.

She was incredibly strong, and was on her way to developing a truly impressive array of bruises on her hands, arms and elbows where she was repeatedly striking them against the rails of the bed. She managed to do this again and again even though she was restrained with the thorough gentleness that only E/D nurses can accomplish.

She was writhing about continuously, intermittently making small mindless noises with her mouth. She was snorting. Yes, she was huffing and grunting away like a small libidinous swine, blowing foamy blood-tinged flecks of aerisolized goo into the air with each breath. The blood was undoubtedly from where she had unwittingly bitten her tongue or a cheek.

Josette mentioned that the woman hadn't even been able to respond to the point of telling them her name.

"Hey, sweetie - look at me," I said in a low soft voice, leaning directly over her face. In reply, I immediately caught a lofted gob of bloody foam on my cheek. I reconsidered, and then from a slightly more strategic angle I continued, "hey - you're in the hospital. We're going to help you, alright? What's your name?"

"Linda," she said clearly, without hesitation.

Zuli's eyes widened and Josette looked vaguely disgusted. I smiled at them smugly and went on asking questions, but I was unable to get anything more from her. I stepped away from the bed and wiped my face off very carefully indeed.

We had been giving her ativan, another one of valium's friends, and now we were up to eight milligrams. For comparison, one or two milligrams of the stuff would leave you or me in a state of numb half-consciousness, looking around in a state of rosy calm for a nice place to get flat. We'd be thinking that anyplace would do, like maybe a busy inner-city sidewalk or the floor of a machine shop. Soon enough, we were up to ten, and it didn't even touch her.

We had been busy doing other things as well; checking her blood-sugar, putting a foley catheter into her bladder and whatnot. We were also trying to get something useful from her erstwhile comrades, but they weren't being terribly forthcoming.

The noisy woman in the next room, who turned out to be another of our batch of four overdose victims, was by now able to speak quite clearly. Unfortunately, all she would do was allow stridently that if we didn't get the restraints off of her, she'd kill us, that we were killing her, that she needed darvon because everything hurt, that she demanded to have a sandwich et cetera, ad nauseum. I found myself thinking wickedly that she had been considerably more pleasant and a better conversationalist when she had been in the throes of the dramatic narcan-retches.

We were now up to twelve milligrams of ativan. Even so, Linda had become even less coherent and had developed a low-grade temperature. She was also starting to look rather red. She continued snorting away like crazy, which permitted me to observe that she had incredibly bad breath.

I saw that she had an upper denture plate and commented on it. The fact that a woman her age had dentures seemed to surprise both Zuli and Josette. She was clearly younger than thirty, and we speculated as to how she might have lost those teeth. Josette figured she might have knocked them out slumping forward into a counter or to the floor in a drug-induced haze, but I took a grimmer view.

"Naw," I said, "She's a shooter, if only occasionally. Bad social situation." I stepped back from the bed, raised my hands in a sloppy imitation of a fighter's stance, and performed a short right jab in midair. "Pow!" I said. "Boyfriend."

Her pupils were dilated, rather the opposite of what you'd expect from a heroin overdose. As punctuation to the writhing, she would occasionally buck like a wounded animal, and the poor EMT student who had come into the room to try to get a blood pressure admitted defeat. I tried next and also failed, and commented to her that it wasn't her fault, thinking all the while that she had a very nice smile. Josette really wanted that pressure though, so she gave it a shot herself. No dice.

Linda was simply moving around too much for a reliable reading to be possible. When an experienced E/D nurse here says its unobtainable, its generally like unto the word of God. She did note that it was somewhere around 128, which was good enough for me, and more to the point for Zuli, who was after all the doc immediately in charge of this patient.


The disturbing thing about all of this was that even in the face of huge doses of a very potent sedative, Linda was progressively and steadily becoming more and more agitated.

Zuli suddenly looked up from where she was writing something and asked, "she's not seizing, is she?"

I had actually been wondering the same thing, and was watching her very closely.

"No, I said. Look at her eyes. Whatever else she might be doing, she isn't seizing - "

We finished the sentence together: "...yet."


Dr. K. was the attending, and he was looking in on us every few minutes - just as much in the dark as we were about what exactly was going on. He had exhibited considerably more foresight than I in getting up near the head of the bed, however. Before examining her eyes and face he thoughtfully donned a surgical mask that had an integral eyeshield. No airborne gobbets of goo for him, no sir. I found myself thinking that I had been, well - rather stupid.

Someone leaned into the room to tell us that these people had been shooting something that might be called Polo. Someone else said they'd heard there was arsenic in it.

Arsenic. Lovely.


I looked down at my watch and noticed that I was about half an hour late for another rads lecture I was supposed to be listening to. With only eight of us in the group my absence would be rather conspicuous, so I made apologies to Zuli, promising to return.

About ninety minutes later, I arrived back to see that there were no less than twelve people in Linda's bay, several of whom I'd never seen before. Zuli smiled at me and told me to head on in to watch because they were about to give her physostigmine.

"Physostigmine - " I echoed in confusion, when it hit me, "Son of a bitch!," I said excitedly, "their shit was cut with benadryl or scopalamine!"


Ari had asked in rounds what you'd give for someone with an anticholinergic overdose, and looked directly at me - the only student there who's going into emergency medicine. I had looked briefly startled and replied from nowhere, "physostigmine." Pulled the answer directly out of my ass, and somehow got it right.


Over the next thirty minutes, we sloooowwwly pushed enough physostigmine to make any "normal" individual very sick indeed, but nothing seemed to happen. Believe it or not, we actually had been hoping that she would calm down within the first couple of minutes and then sit up and speak to us clearly and coherently. Reversal of anticholinergic toxicity is apparently fairly dramatic. When this didn't happen, folks slowly started to wander out of the room and the toxicologist, who had been called in from Children's, decided to get on the horn to a friend of his to see if it might be okay to exceed the recommended dose. Meanwhile, I tried to make conversation with her again.

"Hey Linda - open your eyes hon, look at me."

To my astonishment she did so: after casting confused glances all around the room, she finally focused on my face.

"Linda, sweetie - what's your last name?"

"It was so hot, so hot, everything was hot..."

"I'll bet it was," I replied, stifling a quiet laugh. Anticholinergics do that to you - make you all crazy and rammy, make you feel like you're burning up, make you get all red - the toxicologist had made a brilliant clinical call. "What's your last name?" I asked again.

She told me, and then corrected me when I mispronounced it. She proceeded to answer a couple more questions and then she stopped snorting altogether and settled down into genuine sleep.

"It's the benzos," I told the toxicologist when he came back into the room to see the results for himself, "We crushed her. Hell, let her sleep - she's a lot more pleasant this way than she was before..."

He scratched his head, thought about it for a minute or two and agreed, suggesting that we give her a wee bit more physostigmine just for good measure.

Twenty minutes later, I explained the whole story of what had happened to a couple of classmates working with the unit team that had come down to admit the lot of them, and then I drove my sorry ass home to relax.


I was ecstatic - it had been a wonderful case. I also got to work with a cool resident and a cool nurse, both of whom turn my insides to mush when they smile. It doesn't matter that Josette is very, very married and has a lovely eighteen month old daughter - that's not the point; she still has a great smile.

Home had a slice of cold pizza waiting. Grabbed a quick nap, more pizza, then settled in for an evening's worth of miscellaneous reading: some toxicology, and then the better part of a science-fiction novel.


I stopped back in the department the following morning, and found to my delight that Zuli was working again. Chatted with her for a couple of minutes and then was struck by a clever and novel idea.

"Hey," I said, "There's still about forty-five minutes before rounds - I'm going to head upstairs and find out how Linda is, maybe see if she can't tell me a bit more about what was going on."

Zuli told me she thought this was a great idea, and asked that I be sure to report back to her with what I was able to learn.


I walked up to the unit, and asked my classmate Paul how she was doing. He rolled his eyes and replied grimly that she was doing well enough to demand to sign out of the hospital against medical advice. Wonderful.

I went into her room and found her curled up around the phone, which she had pulled into the bed with her. She was muttering under her breath, stabbing away furiously at the keypad.

"How you doing?" I asked.

"Better than yesterday," she said, grimacing at the phone and reluctantly giving up on it for the moment.

"I was one of the folks who was taking care of you in the E/R yesterday," I told her, "For some reason, I was the only person to whom you would say anything that came even remotely close to making sense."

She shrugged. "That's nice."

"Um - do you remember anything about yesterday? Anything at all?"

"No. Look, I need some clothes - I have to get out of here and my stuff is trashed. Can you get me some of those green thingies you guys wear?"

"I don't think I'll be able to persuade central supply to give me scrubs for a patient."

"Yeah, well I can't go out there in that cold wearing this thing," she said, gesturing at the hospital gown, which had fallen open in front. She glanced down and was suddenly incongruously self-conscious about the bare breast that had snuck out. "Sorry, sorry, man--" she said, pulling it closed. "Where the hell's my coat and purse? I had this nice purple coat, and there are some very important papers in that purse. And where's my necklace? I had a nice gold necklace."

I waited for a moment to be sure that she had wound all the way down. "Alright, let me try to explain to you what happened. Apparently you took an overdose of Heroin and something called scopalamine yesterday morn- "

"No no, man - it was fentanyl and PCP."

Ah. Fentanyl is one of morphine's myriad descendants. Its fairly popular on the street, and incredibly potent. If its not cut exactly the way you expect it to be, its easy to take a lethal overdose by accident.

"Well here's the deal. I looked at the tox-screens from you and your friends this morning." She looked briefly startled. "Yeah, I said your friends. Between this place and three other hospitals, there was something like sixteen of you. Your little group of revellers was the flashy local tv news headline last night."

She was thinking this over.

"Anyway about those tox-screens," I said, "there wasn't even a trace of PCP in any of them. Your dealer sold you some way bogus shit Linda, cut with this nasty stuff called scopalamine."

"Well what did you guys do with my coat and purse?" she demanded.

Linda and I were definitely not connecting. I tried again:

"You were brought to our E/R in the back of a police car because there weren't enough ambulances available at the scene. You came in wearing jeans and a sweatshirt, with nothing else. I'm sorry about your clothes, but you were thrashing around so much that we had to restrain you so you wouldn't fall out of the bed. We had to get your clothes off so we could take care of you, and well - you weren't able to cooperate, so we cut them away. I have no clue what happened to the rest of your stuff, but I guarantee you it was long gone before we ever saw you. Maybe you should try asking your friends."

"Shit. Look, I have to get out of here - are you leaving at lunch or anything? Could you like, give me a ride down to Fourth and Bainbridge?"

Fourth and Bainbridge was not where she had been picked up. It was, however, exactly where the Philly cop told me yesterday that he was going to head next, to make some busts after we told him what the packets found on one of the patients looked like.

Linda was going to sign herself out of the intensive care unit against medical advice and head directly back to the dealer who had sold her the shit in the first place. The rapidly fading thoughts I had been having about trying to get her hooked up with a social worker who might be able to arrange de-tox for her evaporated completely.

"Ah - no. I'm going to be here for the rest of the day," I answered.

"Well what about those other guys, those doctors working out there?"

"They're going to be here for the rest of the day too, probably 'til seven or eight tonight. Listen Linda, you just had an overdose of some truly nasty stuff. You could very easily have died from it."

"Yeah, whatever. I'm trying to get out of here, you assholes won't give me my purse and coat back, my clothes are fucked, and the people I'm trying to call won't answer their phone. If you're not going to help me, could you like, leave me alone? I've got some more calls to make, okay?"

She turned back to the phone, dismissing me.

"At least its warm out there - something like fifty degrees," I told her, "you won't freeze without your coat." She stared at me blankly over the phone. "Best of luck to you," I said, then left her alone with the phone.


Back in the E/D I told Zuli that Linda was indeed conversational. "Not terribly pleasant," I editorialized, "but at least she was speaking in complete sentences."

"Well yeah -- but its not like we do this job because we expect anyone to actually thank us," she observed. "Come on. Rounds are about to start."