by Kay Hadashi
“You make it sound like there’s a but?” she said.
“There is. Pure, high-grade ephedrine is used in hospitals, and both hospitals on the island have had thefts of their stock periodically over the last two years. That coincides with when this Maui meth first started hitting the streets here and in Honolulu. Whoever is making it has suppliers of ephedrine at the hospitals.”
“I can’t imagine pharmacists diverting medications. They study for too long to give up a good career, just to make a few bucks on the side, only to deplete their own stock.”
“Very quietly, we’ve talked to the pharmacists and their techs at both hospitals. We feel comfortable none of them are implicated with the thefts.”
“Who then?” Melanie asked.
“That’s why I wanted to talk to you about it. Any idea of what parts of the hospital use ephedrine in large amounts?”
“Anesthesiologists use it in the OR. Nurses in the ICU and the Emergency Room use it in certain circumstances. It would be found in code carts in every department. What it does is stimulate the nervous system into functioning at a higher level when the system has been dulled because of anesthesia or physiological problems. Mostly, it is used to prevent episodes of catastrophic low blood pressure, and is helpful in treating asthma crises.”
“It’s an emergency drug?” he asked.
“In many of its uses in the hospital, yes. I know there have been pushes for its removal from the national over-the-counter formulary, solely because of its use in the manufacture of meth, but it’s too valuable in the hospital. I see no need to put it in cold and sinus preparations, though. There’s a lot of evidence that shows otherwise in its value for treating rhinitis, especially with the risk of hypertensive crises.”
“I have no idea of what you just said, Mayor.”
“People with high blood pressure need to be careful when taking cold pills that contain ephedrine or similar drugs because they could go into a crisis and suffer a heart attack or stroke. That’s generally the cause of death for people who have overdosed on meth. There are a variety of uses, from so-called brain focus and diet supplements, to mixing it with other drugs to help get higher faster. Maybe that’s what happened to the dead con artists. They might’ve partied and mixed too many drugs, or simply used meth for the first time and overdosed, causing them to have strokes.”
“That explains a lot, thanks.” Nakatani made a note on his pad. “I have to ask. Do you keep a stock of it in your department?” he asked.
“I have a code cart, and it would have a full complement of meds for any situation, along with the defib paddles. I run a cardiothoracic and vascular clinic. It would be malpractice on my part if we didn’t have one in the clinic.”
“How is it stored?”
“In a drawer with the other medications. All code carts are kept locked with a simple plastic lock when not in use. The lock is easily broken if we need to open and use the cart. Once a day, the nurses check everything inside, and on the rare occasion the cart gets used, it gets restocked by the pharmacy right away. I think the ones in the OR and ER are checked each shift.”
“And the med itself?”
“Ephedrine comes in a small vial sealed with a rubber stopper covered by a plastic cap on top, just like most meds. They’re one-time use only. If you need to use some, the plastic cap gets flicked off with your thumb, a needle attached to a syringe is inserted through the rubber stopper, and the med is drawn out. There is usually enough for two doses in one vial, and if I remember correctly, we keep two vials in our cart.”
“This little plastic lock arrangement sounds flimsy, as though someone could easily raid the medications and then stick on a new lock.”
“To a certain extent, yes. But each lock is initialed by the two nurses that put it on, along with the date and time. If there were no initials or date, we’d know someone raided it. Remember, those little plastic locks need to be broken and can’t be used a second time.”
“Why not use a real padlock?” he asked.
“Because if the cart needs to be used in a hurry, and that’s the point since they are emergency carts, the key would need to be found to open it. And before you ask, giving a key to everyone would defeat the purpose of locking it, and invariably, someone would lose their key. The plastic deal works fine in filling the need.”
“What would happen if the nurses discovered the ephedrine was missing when they made their daily check?” he asked.
“They’d report it to the nurse in charge of the department that day, and get a replacement. The nurse would also make out an incident report, which gets filed with the hospital. That’s the same as for any med or device in the cart.”
“They wouldn’t tell you? You’re the clinic manager, right?”
Melanie shook her head. “I’m director of the general surgery program at the hospital. That includes physicians, nurses, and therapists, in the clinic and in the operating room. My clinic manager is Ricky, a nurse who happens to have an MBA. He spends most of his time at his desk, and is responsible for patient satisfaction, staffing issues and schedules, and maintaining our budgets. He’s the one who would fill out the incident report and send it to hospital admin if there was a medication issue in the clinic.”
“Budgets, as in plural?” he asked.
“Hospitals are not cheap places to run. Every clinic and department has their own budgets, an operating budget and a capital budget. Surgery typically has the largest budget in inpatient services. My partners and I create our budgets before the beginning of each fiscal year, but Ricky only maintains it by watching our spending. Most people look at a hospital and think there is one budget that runs the whole place. Dead wrong. Every clinic and department has its own budgets, and are essentially run as separate businesses beneath the umbrella parent company of the hospital.”
“Sounds complicated.”
“It is. Unfortunately, very few doctors are educated well enough in business practices to run their department in financially sound ways. I know I’m not.”
He jotted a few more notes. “Sorry to keep you out so late, Mayor. Just a couple more questions. About these code carts you mentioned. Does every department have one?”
“They do. Most are quite similar, with supplies that would be related to the type of patients they see or the care services they offer. I have a few extra things on my cart related to cardiothoracic patients. Of course, the ER and the OR have the most extensive and well-stocked carts in the hospital.”
“And all these carts would have the same medications?”
“Yes, or very similar. They should all have one or two vials of ephedrine, if that’s what you’re wondering.”
“And they all get checked as diligently as yours?”
“One would hope so.”
“Okay, one last question. How would I go about determining all of those carts had been checked as reliably as yours?” he asked. His pen was poised on his notepad, waiting for her answer.
“Not really sure. You’re welcome to come to my clinic in the morning to see ours. Otherwise, you’d have to go to administration and talk with them about all the other clinics and their carts. But you have to remember every inpatient area of the hospital where meds are given will have a separate stock of ephedrine, not just the vials kept in the code carts.”
“Like an overflow stock?”
“Exactly. If there’s no hurry or need for the resuscitation code cart, a nurse or doctor would simply get the med out of the clinic stock, and then at the end of the day, the nurse would fill out a stock order slip for all the meds the clinic needs and send it off to the pharmacy. By the next morning, it would be replaced by a pharmacy tech. But now we’re straying from ephedrine. Sorry.”
He made a note and flipped his pad closed. “Okay, this is way too complicated for so late at night. What’s a good time for me to come to your clinic in the morning?”
“I get there at six-thirty, and we start seeing patients at seven. Anytime betw
een then is fine with me.” She opened the car door and got out, but before she closed the door again, she leaned in and smiled. “If you bring a box of doughnuts, you’ll make friends with my office staff.”
The light rain had turned into a downpour and even with running the short distance to the back porch, she got soaked through her clothes. Inside the kitchen, Georgie was just putting away the last of the dinner dishes and pans.
“Does Uncle Nate come here for dinner very often?” the nanny asked.
“First time. He made it sound like he wanted some of your cooking. Which was quite good, by the way.”
Georgie hung up the dishtowel. “I should go check on Thérèse and the baby.”
“Georgie, you’re off duty once either Josh or I get home. And don’t let these guys start talking you into doing things like cooking dinner and washing the dishes. Both of them are lazy enough to let volunteers do everything around here. And believe me when I tell you those two are the last of the male chauvinist holdouts.”
After finally being convinced she was done working for the day, Georgie went to her room and closed the door. Melanie’s next stop was in Thérèse’s room.
“So, how was your first day with the new nanny?”
“Okay.”
“Just okay?”
“She doesn’t know as many games as you.”
“What kind of games?” Melanie asked, sitting on the floor with her daughter. The girl had a children’s Scrabble set spread out on the floor and had been making words from the tiles.
“Word games. She only knows English.”
“Oh, I see. Hard to play guessing games that way, huh? But you can still play those games with me. And maybe you can be her teacher? She doesn’t know any Japanese at all?”
“Just the easy stuff.”
“What about Spanish?”
“Not so much. Her daddy wasn’t the pwesdadent like yours was.”
Melanie spelled a word on the floor with Scrabble tiles. “Well, your daddy doesn’t have to be President for you to know Spanish.”
“He don’t?”
“Nope. Your daddy doesn’t know any Spanish at all.”
“Momma, you and your momma lived here a long time ago, huh?”
Melanie spelled another word on the floor with tiles. “Yep, sure did.”
“Did your daddy live here?”
“Nope. He lived in California.”
“Did you ever live at your daddy’s house?”
“For a while. What are all these questions all of a sudden?”
“Jus’ wondering.”
“Well, you can wonder in your dreams. Right now, I want you to read what I spelled with your letters.”
“Watashi wa…anata o…aishi…te…imasu.” The girl’s face twisted with confusion.
“Say it all at once.”
“Watashi wa anata o aishiteimasu. Oh! I get it.”
“What’s it mean?”
Thérèse jumped up from her position on the floor and tackled Melanie to the floor. “I love you too, Momma!”
Once Thérèse was in bed, Melanie went around the house tuning off lights and checking doors. The rain continued to fall hard, pouring off the roof in heavy waves, splashing on the ground outside. It was a cheerful sound to Melanie, always had been while growing up. The rain usually brought a cool breeze, natural air-conditioning in the tropics, giving her the best nights of sleep. While Josh sat at the desk in the corner working on grading school papers, Melanie played with the baby on the bed.
“What was all that out in the car with Nakatani?”
Flat on her back, Melanie held the baby above her and played like he was an airplane, getting giggles out of him. “What do you mean?”
“You guys talked for an hour before dinner, and then for another hour after dinner. Alone. In his car. In the dark.”
“So?”
“In the dark?”
“Okay, you caught us. We were making out like teenagers at Lover’s Point. Happy?”
“Not really. What were you talking about?”
Melanie started a new game that involved getting Chance to crawl. “The investigation into the deaths of those two tourists.”
“Anything new about that?”
“Not much. And if there was…”
“You wouldn’t tell your own husband,” he said.
“The more the public knows about investigations into serious crimes, the better the perpetrator can defend himself.”
“That’s all you talked about?”
“Georgie might’ve come up, but yeah, that’s about as interesting as my life gets anymore. Talking about dead people.”
“Are you seeing him?”
She stopped playing with Chance for a moment and looked at Josh. “What?”
“Are you guys getting together?”
She swore at him. “And your stupid ideas.”
She went back to playing quietly with the baby while he corrected papers. “Make those appointments yet?”
“You’ll be happy to know Pop and I go in next Monday afternoon to your specialist.”
“She’s not a specialist. She’s family practice, exactly what the two of you need. It might be a good idea if your parents start looking for a geriatrician, though.”
“She? What do you mean, she?”
“Doctor Reyes is a woman. How many times have I been to her while we’ve been married and you never knew she was a woman?”
“You’re the one that went to her, not me.”
“Well, guess what, buster? You and your father are going to her now, too. And guess what else? She wears size large exam gloves.”
***
Detective Nakatani showed up in Melanie’s clinic first thing in the morning, as promised. Melanie and he stood behind the two nurses as they opened the code cart and made their daily check of supplies.
“So, everything is there, right?” Melanie asked when they finished.
“Everything is there, outdates checked, and defibrillator tested. Can we close it up?” the nurse asked.
When Melanie looked at Nakatani, he was rubbing his chin, looking with curiosity at the drawer of medications.
“May I look at one of the ephedrine vials?”
Melanie handed him one. “That’s the plastic cap I was telling you about. Beneath that is the rubber stopper. The label clearly indicates the name of the medication, and the concentration.”
“Are there different companies that make this stuff?”
“Probably every large pharmaceutical company makes the most common drugs, and this would be one of them. Things like cold preps, pain meds, aspirin, and common cardiac meds are the bread-and-butter products of drug companies. Each company has its own brand name for what it makes, but there are generic trade names for everything also. Since hospitals are budget minded, they generally get what is most cost-effective.”
“You mean they get the cheapest stuff they can find?”
“No, but since they buy some meds in bulk, they can get good deals on products made by the more prominent companies. There are other drugs that are too important to risk low quality, and very few companies are licensed by the FDA to manufacture those.”
He gave back the vial of medication and the nurses closed and locked the cart, something else Nakatani watched carefully.
“May I have one of those little locks?”
The nurse gave him a handful before leaving them alone.
“You sure are curious about those,” Melanie said.
“This is how it’s done with all medications?”
“Not narcotics. Those are kept under lock and key, actually two layers of locked cabinet doors need to be opened, and by separate keys.” She led him to the clinic’s supply of narcotics, a metal safe built into the wall. “Two licensed personnel are required to open, remove, and check out any narcotic. We have a logbook to keep track of the nurse or doctor checking it out, the name of the patient it is given to, and the date and time. If any part of the med
is not used, it is squirted down the drain while witnessed by two licensed personnel, and even that is signed in the logbook. The FDA and every hospital and health care institution certification organization takes all that very seriously. And just like the meds in the code cart, these are counted every day, just to be sure nobody has stolen any.”
“Does that still happen?” he asked, taking more notes.
“It’s called diversion, and yes, it happens far too often. But ephedrine is not a narcotic.”
“Well, this has been quite the education,” he said. “It looks like you guys keep a sharp eye on things. Who would I talk to in administration about looking at more of these carts?”
Melanie clenched her teeth for a moment. “That would be Andrew Carson. He’s responsible for overseeing all patient services here at West Maui Med.”
“He’s a doctor?”
“Not even close.” She took Nakatani into her office and closed the door. “Andrew should’ve been an image consultant. All he cares about is how something looks, and mostly himself. If you mention my name when talking to him, you won’t get far.”
Nakatani looked to be suppressing a grin. “Why’s that?”
“When I first finished my training in California and came back here for my career, he had just moved in as a junior administrator. It didn’t take him long to brownnose his way up the career ladder. Now he acts as though he runs the place single-handed.”
“What’s that got to do with you?”
“We…” Melanie had to unclench her teeth again. “…dated.”
“Was it a serious relationship?”
“I think a ring was involved for a week or two, but honestly, I’m still trying to block all that out of my memory. Just the sight of that…person…in the elevator turns my stomach.”
Nakatani chuckled. “I’ll do my best to keep your name out of my questions for him. But he would know if there have been thefts of ephedrine?”
Melanie nodded. “Anything related to patient care, including all incident reports, would go to his desk. How closely he looks at them, or if he takes any of it seriously, is anybody’s guess.”