Just Here Trying to Save a Few Lives

by Pamela Grim

  “Did he say why he did it?”

  The commander shrugged. “He said he didn't wanna go back to jail.”

  “That was the reason?”

  “He said he was sick and tired of living in a jail cell and he just didn't want to go back.”

  “Sounds like a suicide mission.”

  “Yeah, the only problem was—we missed.”

  The trial started one blistering July day, thirteen months after Jay Stryczek was discharged in stable condition to the county jail. Why he did it, what he was thinking in the few seconds that the scene went down, turned out to be the crucial issue. There was no question that Jay Stryczek had killed a police officer. The question was whether it was first-degree murder—maximum penalty the electric chair—or second-degree murder, maximum penalty life imprisonment. The deciding factor involved intent. To convict of first-degree murder, the prosecution had to prove that the murder was planned and that death was the intent. To do that, Jay Stryczek must have intended to kill a police officer when he grabbed his assault rifle and stepped out of the car.

  “Of course he intended to use the gun,” Bill said. “Why would he have picked it up and gotten out of the car with it?”

  “Well, it doesn't matter what the truth was, all that matters is what the jury believes.”

  “Yes, but who could possibly imagine getting out of a car with an assault rifle for any other reason?”

  I shrugged. “No idea.”

  The trial lasted two weeks, during which the defense argued that Stryczek had gotten out of the car with the gun in order to “menace” the police officers—that there was no intent to injure, that the gun went off accidentally.

  The day the verdict was to be announced, someone brought a little portable TV into the ER. We monitored the news channel throughout the shift, and when the newscaster announced that the jury was ready to read the verdict, all of the staff clustered around the set. I stood off to the side, leaning against the wall, arms folded, watching, thinking. Remembering.

  I wish I could say that the strongest memory I had of Sheldon was when he sang Cole Porter to that whacked-out PCP player while he held him in a headlock. But it's not. My thoughts always go back to a place I never was, inside a patrol car that had just pulled over a guy with a bad taillight. I keep thinking it's me at the wheel, groping around, reaching for the flashlight, the sound of the door as it opens, the crunch of boots on gravel. After all…

  Imagine it was you.

  As you walk forward toward the car in question, you see everything happen in slow motion; the car stops, the door opens, there's the shadow of the man with a dullish angular reflection at his side, something that moves with his arm. The man himself is standing now before the door, legs apart, braced, not moving forward, not moving at all, and you see a gesture, as if the man had a gun, a shotgun. No, a rifle. No, you think, what a mess. And then: No, this cannot be. That's the point when you raise your hand to your gun and as you do, you think, I'm too late. And, Not now, not to me. This cannot happen to me. I have a family and plans, a future, a clear and wide, wide future. My life can't end just like this.

  7

  HOW TO WRITE A PRESCRIPTION

  APATIENT SITS before you, gazing at you, while on your desk, under your pen, is a square of paper. Printed at the top is your name, followed by “M.D.” Or the name of a hospital, say “General Hope Memorial.” A line for your signature is on the bottom (underneath a caption: “May substitute __yes __no”). This is the blank prescription.

  The patient is waiting for you to write for something that will make him feel better. This is your job. You start scrawling something on the form, something from another place, another time. You and the pharmacist both know what's being written here, but the patient won't understand a thing. He may think the message is secretly encoded using bad handwriting. But it's not, or not only.

  The hallmark of the paper, the confirmation of the scrip's authenticity, is the use of Latin (with an indelible shadow of Greek). This is not the Latin of modern science; this is the Latin of hell-bane and devil's wort, powdered mandrake root and eye of newt. You may be writing for a drug invented no earlier than yesterday, but the language of the prescription will echo from the most distant past of medicine. And the human impulse behind the prescription will be the same now as then—a mixture of hope and wishful thinking, science and sorcery.

  You begin by writing the name of the drug you want (using a ballpoint pen with the name of some unbelievably expensive antibiotic printed across the clip, gift of a drug rep). Traditionally, all drugs have two names. The first is the scientific name—the generic name. Usually this reflects the chemical properties of the drug, shortened in some way. For example, the drug 7–choro–l, 3–dihydro–l–methyl–5–phenyl–2H–l, 4–benzodiazepine–2–l, has a name no one but a chemist could remember. Its generic name is easier: “diazepam.” But it has another name as well. That's the proprietary, or trade, name, the drug company's patented name for the drug. For this drug the proprietary name is “Valium.” This most people have heard of, the name with the most resonance. But all of them are the same drug.

  What's in a name? Well, after all the bad press Valium received during its ascendance, drug companies rushed to make congeners, related drugs with small variations in the chemical structure, each one requiring a new name. Solid citizens who wouldn't dream of taking Valium now pop its fellow drugs, identical in almost every way, including addictive properties.

  You glance up. Your patient is still waiting for his prescription. Let's say he is waiting for a scrip for acetaminophen with codeine, trade name Tylenol #3. You can write down either name (but usually only medical students remember the generic names). Being a doctor, of course, you don't worry too much about the spelling. Bad handwriting helps hide many errors—although you can't be too cavalier. The hapless street addict who presented his (presumably forged) scrip for morphine written as “MOFENE,” followed by “totel 10 dollers,” did not get his drug.

  After the name you write the number of pills to dispense, say “#30.” Below this you write the mysterious word sig. Latin again. It is an abbreviation for signa—-(imperative of the Latin signo, to set a mark upon). Hardly a physician knows what this word stands for, though they may write it twenty times a day. Used in prescriptions since the Middle Ages, it introduces the part of a prescription containing directions to the patient—not that many patients would be able to decipher what follows. (The Latin hallmark is everywhere and nowhere.)

  The next step. You must write down the number of pills to be taken at any one time, but you can't write this in Arabic numbers. Tradition demands you use lowercase Roman numerals: i, ii, iv, etc. Next, you write how the drug should be taken—that is, by what route. You must write this in abbreviated Latin, of course, even though it would be just as easy to write what you want in English. The typical abbreviations include: po (peroral, by mouth); pr (per rectum, by rectum); ou (oculus uterique, each eye); sl (sublingual, under the tongue—where a rich rete of capillaries sweeps the drug almost immediately into the bloodstream).

  After this, another mysterious signifier—the code for the number of times a day the drug should be taken: bid means bis in die, twice a day; tid, ter in die, three times a day; qd, quaque die, every day; or, as in the case of this particular prescription, you will append “prn.” This is Latin for pro re nata, loosely, according to need. Now you are finished. Well, almost. There is one more thing, something which yanks you back to the twentieth century. Tylenol #3 (T#3) is a controlled substance. This means you need to include your DEA number with the scrip. The DEA number is your assigned designation from the U.S. Drug Enforcement Agency. Your particular number allows the Feds and state officials to monitor your prescription habits, albeit in a shadowy way. Get frisky with the prescriptions for Percocet and somewhere someone is supposed to notice.

  What makes T#3 a controlled substance? Controlled substances are those drugs designated by the DEA as having addictive pot
ential. There are five classes of controlled substances. Class V (note: not 5) are medications that have minimal abuse potential and are sold without a prescription. Examples are over-the-counter cough syrups with minuscule amounts of codeine. Class IV drugs are prescription drugs believed, by the federal government anyway, to have relatively low abuse potential. These include Darvon, Talwin, Valium, and Xanax. Class III drugs are considered more addictive; they include anabolic steroids and hydrocodone. Class II contains the strongest analgesics—pain medicine—that can generally be written for: morphine, methadone, methamphetamine. These are drugs thought to be medically useful but also to have very high addictive potential. Finally, Class I drugs are usually available only to researchers. These are drugs which are considered both to be highly addictive and to have no beneficial medical use: heroin is a Class I drug. So is marijuana.

  So you put down your two letters and the following seven-digit number. Now you are finished.

  But what does a prescription for 30 T#3 mean? Well, different things to different people. For some patients, the ones with the occasional headache, this prescription is something to fill, use once, then put in the back of the medicine cabinet, where it will sit forgotten for months or years until it is rediscovered at four A.M. by a patient in the act of looking for something for an acid stomach. To others, a businessman, a new mother, a high school principal, a cop, people under pressure, “T#3” is something they know will take the edge off that nagging back pain. Something that will help get them to the end of the day, daily, in fact. Something that's there when it's needed, not really a “crutch” but…well…helpful.

  Then there are the small-time addicts, people who, for whatever reason, have gotten themselves hooked on codeine and now troll the medical field looking for a drug source. They come into the ER all the time. They usually have a story, a transparent story if you know what to look for. You could even profile these guys—like airplane hijackers or drug smugglers. Glance down the chart and alarm bells go off.

  One typical story goes like this. The patient is from out of town, no access to a regular, or, as you like to call them “real” (as opposed to ER) doctor. He has a history of chronic low-back pain that requires a mountain of Percodan—at least—to take the edge off. And usually a shot of Demerol as well. He's allergic to a lot of different medicines: coincidentally these happen all to be mild drugs useful in treating chronic pain.

  Tonight the pain is terrible, terrible, the worst it's ever been.

  “Please, Doc, you got to give me something for the pain.”

  Some ER doctors just give them the shot and the prescription. How can you tell the pain is or isn't real? they say. But you've always thought that was part of the job, making that assessment. And giving a prescription-drug addict more drug is not going to do him or her any good.

  You stand in the room, gazing at the patient, arms folded. He or she could be anyone, but tonight he's a forty-five-year-old man, well dressed; a handsome leather briefcase sits on the floor beside him. A reminder: addiction transcends social classes.

  He says he has excruciating back pain, but he makes all the wrong moves. He sits up in a way people with real back pain don't. He grimaces every time he moves his leg, a kind of hokey facial expression, almost a parody of someone in pain. When you touch his back, he bunches up his face horribly and beats on the bed railing. “That hurts; it hurts, Doc,” he tells me, rubbing his right leg. “And it's weak, I tell you, weak.”

  He's flunked the sitting straight-leg-raising test, and now you are going to try the Hoover test. Both of these tests are used to differentiate “organic” (i.e., “real”) from “functional” pathology. They help answer an important question often raised in the ER. Is this true disease or drug-seeking behavior?

  The Hoover is a simple test. You have the patient lie down, then you place your hand under his left heel. You ask him to raise his right, his weak, leg. Normally, if someone has true weakness, he or she will attempt to lift the affected leg by placing pressure on the contralateral, stronger leg. People who are faking weakness usually don't brace with their other heel. When they don't, you have a positive Hoover. While this test is not 100 percent accurate, in this case it definitely confirms what you suspected.

  “I'm going to recommend…Tylenol,” you say.

  “Doc, you gotta be kidding.”

  “I'm not kidding.”

  “I need something stronger. I need a prescription.”

  “The answer is no.”

  “Why not?”

  Because of the nature of your addiction, you say to yourself. This thought is translated as: “Because you'll only be back tomorrow for twice as much.”

  “No, I won't, Doc. I swear I won't.”

  “The answer is no.”

  “Doc. No, wait.”

  I leave the room and walk back down the hallway. All the time I can hear the echo and reecho, “Doc, please. Please. Please, Doc.”

  That echo is what addicts always sound like. A constant plea: I need…I need…I need…

  Then there are the dealers in prescription drugs, always looking for a way to score something interesting. For them T#3s are small potatoes; codeine really doesn't have much of a high, and acetaminophen toxicity precludes using the drug in high doses at any one time. Still, T#3s do have a street value. After all, they can take the edge off a really bad narcotic withdrawal or blunt that inevitable postcocaine letdown. If a dealer could get a scrip from some ER doctor for, say, fifty pills, he'd gladly take it. No problem.

  Then, lastly, there are the doctors who use. After all, what potential addict has such delectable access? The addicted doctor has to be careful, though. That little DEA number that seems the key to paradise may come back to haunt him. It's bad form (also illegal in most states) for a doctor to write a prescription for himself. How to avoid this? Well, one way is to write a prescription for an accomplice and split the outcome (called “splitting scrips,” very illegal). Another way is to go into a profession where prescriptions aren't needed and access is no problem. Something like anesthesiology, a job with phenomenal drug temptations (and the highest addiction rate in the business). Anesthesiologists routinely handle drugs of transcendence—nirvana beyond any ordinary user's imagination. And it's relatively easy to hide the use, early on at least. You just mark down two bottles of, say, Sufenta: one for the patient and one for you. The only thing that makes it difficult is the nature of the addiction itself. Always, always, after a while, one vial is not enough.

  And so the addiction comes full circle, the doctor is now the addict.

  You sigh and put your pen down, not really sure how you got on this train of thought. The prescription is finished: “Tylenol #3, #30, sig: ii po, qid, prn pain.” You hand it over to your patient. He smiles. “This should do it,” he says. He leaves happy and you remain behind, rubbing your eyes. There is, you think, one more role a physician can assume when writing a prescription, one not obvious at first glance. That is the doctor as enabler, the guy who will write a prescription for pretty much anything the patient wants, even if it is unreasonable. Or even worse: the doctor as drug pusher.

  Every city has one: the guy who will prescribe diet pills to anorexics, downers to alcoholics, rainbow-colored pills to patients with chronic fatigue syndrome and Demerol to anyone who doesn't look like an undercover agent for the Feds. He treats “soft diseases,” diseases which are hard to quite pin down. Chronic low-back pain, whiplash, fibromyalgia, work-related disabilities of questionable pedigree. A good pill-pushing doctor can jack the patient up on an array of heavy-duty narcotics or stimulants, all the while extracting a small fortune in insurance claims and patient billing. These patients become addicts of the worst sort to treat. They have the perfect excuse to take drugs: my doctor told me to take these.

  But you're not an enabler. The idea is horrifying, you think, and as you do you casually flip through this patient's chart. It's now that you realize this is the fourth prescription for T#3s you've given th
is patient this year. But he's got that arthritis, you think, shaking your head, while at the same time you wonder: “Is he seeing other doctors for the same thing?” That's when you notice you've given him two refills on a sleeping medication you don't remember ever writing for him to begin with.

  An innocent prescription, you think. What harm could that do? You shrug as you close the chart. Then you stop. You see a man standing before you, a tall, distinguished-looking man, very Marcus Welby, wearing a white lab coat and a stethoscope draped around his neck. The most despicable doctor who ever lived.

  Dr. Daiquiri.

  8

  DR. DAIQUIRI

  I WASN'T ON DUTY THAT DAY. Mary, the unit clerk, told me the story. It was a Sunday afternoon, a beautiful day outside. The ER was quiet, at least for everyone in the back. But when Mary went out to registration, she saw that up front, in the ER waiting room, the place was packed with people sitting, sweating in the still air. Weird. She went back to her desk in the ER, where she had a good view through the glass door leading into the triage office. There she could see Phil, the triage nurse for the afternoon, sagging in his chair, reading a magazine. The whole day had become so torpid and Sunday-like that you could hear the flies buzzing in the window, accompanied by the ghosts of old-fashioned ceiling fans.

  Someone came into triage and sat down. Phil busied himself with taking the vital signs and generating a chart. Mary, bored, returned to the crossword puzzle before her. After a few minutes Phil came out of triage carrying his duffel bag back to the nurses' lounge, apparently to put it in his locker. A few minutes later he returned. Mary watched him come and go; it was that kind of day.

  A few minutes later another patient came into triage. Mary was idly watching as the man, a big guy, sat in the triage chair and offered his arm to Phil. Phil was wrapping the blue blood pressure cuff around the man's arm when it happened. The thing we dread most in the ER. The patient went berserk. He stood up, grabbed Phil by the shoulders, stood him up, turned him around, slammed his face up against the wall and held him there with his forearm against Phil's neck.