Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (20 page)

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 this 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

D
R
. D
AIQUIRI

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.

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 looked 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.