Just Here Trying to Save a Few Lives

by Pamela Grim

  Mary hit the panic button, a little red knob under her desk that immediately signaled security. “Jesus Christ, no,” was all she had time to say. The patient had leaned up against Phil, right arm still trapping him against the wall while his left traveled up and down Phil's back.

  Security, actually Larry and Curley (“All they are missing is Moe,” Mary once told me), ran into the triage room. As they did, the patient—still leaning against Phil, trapping him against the wall—raised his hand, stiff-armed, holding up something, not a gun; that's all Mary could see. Larry and Curley looked at whatever it was and scrambled out of the room. As they were scrambling to get out, all the men who had been sitting in the waiting room now crowded into the triage area. Some of them had guns.

  “Hit the floor,” Mary shouted. “We got a situation in triage.”

  Almost everyone in the ER had lived through a shooting the year before. They knew what to do.

  There was a moment of silence or, rather, just the sound of voices coming from triage. No gunfire. After a long pause, Larry opened the door that led back to the ER. “Hey, guys,” he said, looking around. He lowered his gaze. “Why are you on the floor?”

  Mary raised her head and pointed. “Triage.”

  Larry pawed the air. “Oh, they're just FBI.”

  More heads popped up.

  “It's a drug bust, guys,” Larry said. “It's an arrest.” Mary lumbered up, dusting off her scrubs. “Who the hell are they arresting?”

  Larry shrugged as if it should be obvious. “Phil,” was all he said.

  This is the story: apparently, unbeknownst to all of us, Phil, a nurse for ten years, also had dealt drugs for a living. At some point he figured out that one of the safest times to do a drug drop was when he worked as the triage nurse in the Emergency Department. The dealer/drug delivery man could then come in as just another patient. They would swap identical bags, and the dealer would get his blood pressure checked and drift back out, never making it even to registration: LWBS (left without being seen). Perfect. Just one time, though, this time, some wiseguy must have tipped off the Feds. The waiting room in fact had been filled by undercover agents dressed in jeans and baseball caps, bulletproof vests under their sweatshirts.

  Phil had put a bag filled with $250,000 worth of cocaine in his back locker. Everyone watched as this modest fortune in a duffel bag was hauled out by a federal agent wearing a Cleveland Indians T-shirt.

  Mary called the nursing supervisor. “You're going to have to get us some more help down here,” she told her. “We've just lost our triage nurse.”

  “What happened?”

  “You really just don't want to know.”

  Drugs. Drugs in the ER: everything, every variety, every color, shape, chemical state, every degree of licit- or illicitness. All the uppers, downers, laughers, screamers, you could possibly imagine: marijuana, angel dust, crank, cocaine (powder, freebase, crack, rock, crystal). Wet, blunt, acid (orange sunshine, purple blotter, windowpane), black beauties, white bennies. T's and Blues, speed-balls. Strychnine, lidocaine, mannitol and other filler. Then there is the legal stuff: Thunderbird, Everclear, MD 20/20, Sterno, paint propellant, cooking sherry, nitrous oxide (occupational hazard of dentists), Sufenta (occupational hazard of anesthesiologists), methylphenidate (Ritalin) and Robitussin. Rush, Buzz and other carpet cleaners. Rohypnol (date rape drug). Also: Mexican Quaaludes, GHB, youngana (Figian), grappa, Ecstasy, ma huang, airplane glue and nail polish remover. White Out, anabolic steroids, “Vitamin K” (ketamine), kif, magic mushrooms, smoking while wearing a nicotine patch.

  In the ER we see every imaginable end-stage addict, from the vole-faced punk scarfing the evidence during an arrest to the strung-out hooker who has run out of veins, to the young kid, just seventeen, his creosote hair still slicked back perfectly in place while we frantically try to defibrillate his dead heart; no go, nothing left.

  Then there is the other side of the drug problem: addiction. As a doctor I stand in awe of all addiction. We as physicians are schooled in the furthest reaches of human understanding, yet we are so powerless here. Does any other disease have a prognosis so dismal? Response to therapy—what, 17 percent? And the best we can do for therapy now is to invoke the gods.

  The doctor whom I am to replace for the afternoon shift is writing out discharge instructions for the patient in room four. On the pink form he prints in big block letters: CUT DOWN ON YOUR DRINKING OR YOU WILL DIE.

  My first patient continues the theme. He is an old man, gnarled and bald, stick thin and very drunk. I look at him and think of him as a child of the Great Depression. I know his life; he stays in the fleabag Burnside Hotel, rooms let by the week, sink by the window, toilet down the hall. Television in the lobby. Lives on social security, drinks when he can.

  “Wassamatter?” I ask him. He gazes off over my shoulder for a while, then finally says, “Cough.” And he does so, producing the moist, musical explosion of a terminal smoker. “And chills,” he adds.

  “You ever have TB?” I ask him.

  “Not me, but my dad did,” he tells me. I shudder. This story has been engraved in my heart. What is the differential diagnosis: a sorry soul at the end of the line, a dead-end drunk with terminal bronchitis?

  “You gotta quit smoking,” I tell him.

  “Yeah, doc, I know. But I need something for the cough.”

  “I can write you for some tablets…”

  But he has an agenda. “Doc,” he says, “what I really need is some cough syrup, some of that codeine stuff.”

  “I can write you for something better.”

  “No, Doc. I'd rather just have cough syrup.”

  I sigh. It's not worth the trouble to say no. And there it is. The doctor as enabler. Is that where this case is going, I wonder, or will it, as always in the ER, be about something else, something completely unexpected?

  Eight A.M. Monday morning, one week after Phil was arrested and two days after a pleasant thirty-two-year-old male with a sore throat turned into a psychotic werewolf before my horrified eyes. Please, nothing unexpected today, I grumbled to myself as I picked up the first chart. Chief complaint: “weak and dizzy.” I shrugged. If addiction is the bête noire of emergency medicine, then its bread and butter is the weak and the dizzy. We see a half dozen, at least, on any busy day. Usually nothing is really wrong. You just slog through a workup, coming away after a few hours and thousands dollars of tests with very little to show for it. That morning as I paged through the patient's chart, noting the vital signs (normal) and her insurance status (Blue Cross) I felt the heavy hand of weariness rest on my shoulder.

  Another weak and dizzy.

  I leaned into the acute room and glanced at the patient. She was a well-dressed, middle-aged woman. From the distance of the doorway, she looked the part of a respectable citizen with a vague complaint. Blond, pretty, lots of makeup. But as I walked up to the bed, I could see that the makeup had been pretty haphazardly applied; lipstick didn't exactly follow the lip line, the mascara was smudged and the eyeliner had wandered shakily. (I was being very careful about makeup around then. The week before, I had treated a perfectly delightful woman of ninety-four for a wrist fracture only to discover he was, perhaps, the world's oldest living drag queen.)

  Alisa, the charge nurse, was standing beside the woman trying to fill out her chart. “Medication?” she asked the patient.

  The patient had a tentative air. “I don't know,” she answered, looking around as if she had no idea where she was or how she got here. It took her a moment to focus on my face when I stood beside her and then even longer to register that I was the doctor.

  “'Lo,” she slurred to me.

  Alisa continued. “Marilyn, do you have any allergies?”

  “Let me see,” Marilyn said. She gazed off, eyes blank, one hand fumbling with a tissue. “Do I…do I…” She turned back to Alisa. “Do I what?”

  “Have any allergies.”

  “Oh,” she said, lips puckered. She l
ooked down at her hands as if she didn't recognize them as hers. “I don't know…” She looked up at me and there was an expression of real fright in her eyes. “I'm sorta…I just don't know.”

  What was the matter with this woman? I asked myself. I moved to swap places with Alisa but was distracted by the patient's handbag on the Mayo stand. It was the kind you see in fashion magazine ads: calfskin, soft as butter and the color of wet sand. A couple of prescription pill bottles had spilled out. I tipped the bag toward me and glanced inside. More pill bottles, a dozen maybe.

  “Can I look at these?” I asked.

  Marilyn made a feeble gesture of embarrassment. “I can't remember exactly what…I'm on. I'm on so many…” She trailed off.

  I started pulling the bottles out of the bag while Alisa wrote them down.

  “Zoloft,” I said. An antidepressant. “Ventolin syrup.” That's for asthma, but usually given only to children. “Klonopin,” a tranquilizer in the same class as Valium. “Tylenol #3,” pain medicine; “Vicodin,” more pain medication; “Ativan,” that's like Klonopin except shorter-acting; “Fluphenazine,” a diet pill that probably shouldn't be taken with Prozac; “Halcion,” another Valium-like drug; “BuSpar,” an antianxiety drug; “Darvocet,” more pain medicine; “SOMA,” a muscle relaxant; “Tylenol #4”—maybe in case Tylenol #3 wasn't strong enough. And at the very bottom, a large bottle of plain aspirin. Almost empty.

  “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 parame
dics' 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.