Please, no surprises today," I thought as I picked up the first file of the morning. Marilyn Baker. Chief complaint: "Weak and dizzy." I leaned into the acute room and glanced at the patient, a pretty, well-dressed woman in her forties. But as I came closer, I saw that her face had a smudged look: crooked lipstick; shaky eyeliner. Alisa, the charge nurse, was standing beside her, trying to fill out her chart. "Medication?" she asked.
"I don't know," the patient answered, looking around in a daze. "'Lo," she slurred to me.
Alisa continued. "Marilyn, do you have any allergies?"
Marilyn gazed off, eyes blank. "Do I . . . ? Do I . . . ?" She turned back to Alisa. "Do I what?"
"Have any allergies?"
"Oh," she said, looking up at me with frightened eyes. "I'm sorta . . . I just don't know."
What is the matter with this woman? I glanced at the patient's handbag. 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.
"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 down the names of the drugs.
"Zoloft," I said, an antidepressant. "Ventolin syrup," for asthma, but usually only given to children. "Tylenol with codeine Number 3," pain medicine. "Vicodin," more pain medication. "Halcion," a Valium-like drug. "BuSpar," an antianxiety drug. "Darvocet," more pain medicine. "Soma," a muscle relaxant. And at the very bottom, a large bottle of plain aspirin--almost empty.
"I took all those," Marilyn said, gesturing toward me.
"All these pills?" I asked.
"No," she said. "Well, no, but yes. Those." She pointed at the aspirin.
"How many?" Alisa asked.
"I don't know."
I dumped the few remaining aspirin pills into my hand. "You mean the aspirin? You took all the aspirin?"
"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 blankly. "I think I wanted to kill myself. Don't tell my husband."
"Ma'am," I said, "do you take all these pills?"
"I just take them like I'm s'pose to."
"All of them?" I said. I knew the answer. I even knew the name of the doctor who prescribed them.
My patient nodded. "Just like Dr. Daiquiri says."
Dr. Daiquiri. Good old Dr. Daiquiri. Also known as Dr. Feelgood, the physician with a prescription, a prescription for any problem you may 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 his patients to the er for a shot when the thousands of pills he prescribed weren't enough and the pain had become "severe." 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 the pills that Dr. Daiquiri prescribed.
I stood staring 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--the kidneys, the liver, and the brain--can shut down forever, depending on the amount ingested. Patients can seize, develop heart arrhythmia--in essence, crash and burn in the blink of an eye.
Marilyn was so confused she couldn't tell me how many pills she had taken. But everything she did tell me added up to attempted suicide by aspirin overdose.
"Honey, we're going to have to put a big tube down your nose to suck those aspirins out."
I was counting the number of pills in each bottle when Alisa walked back in.
"Husband's outside," she told me. "I'll get started here."
Marilyn's husband was just as well-dressed as she was. I winced at the thought of what I looked like, a sleep-deprived doctor in a lab coat splattered with blood and Betadine.
"It's those pills," he said fiercely.
"Has she ever taken an overdose?"
"Overdose?" he asked sharply.
"Aspirin. I think. I'm not sure, though; she's really not making much sense."
"Aspirin," he said with wonder. "Well, she's taking nearly everything else."
"All prescriptions?"
"Dr. Daiquiri," he said shortly. "She began seeing him last year when she tried to quit drinking. He put her on all these pills, and things are even worse now than before. Can I see her?"
We walked back to the acute room. Marilyn was lying there in all the glory of an er washout. She had an enormous lavage tube sprouting from her nose and there was charcoal everywhere. Charcoal is a sort of generic absorbent; it will bind many toxins and cause them to pass out of the gut harmlessly. It's also black and syrupy, and it gets all over everything. Marilyn had already vomited some back up, not unusual for the stuff; it was down the front of her blouse, matted in her hair, on the sheets, on the floor.
"I've tried to get her to see a real doctor, a psychiatrist, anybody," her husband explained, "but that quack has her strung out on so many pills she doesn't have any idea what she's doing. She lives for those damn pills. Why don't they prosecute that man?"
I shook my head. Dr. Daiquiri was very smart. He knew what he could prescribe and how to stay on this side of the law. He had threatened several doctors with legal action after they complained to hospital administrators about his prescribing too many narcotics.
I glanced at Mrs. Baker. She was gazing into the distance now, one hand clutching at her hospital gown. The hand was twitching, trembling, and then it scraped, clawlike, across her chest. Her head bent back, and the twitching extended up her arms and shoulders. Another heartbeat and I realized what was happening. "She's seizing," I shouted.
I rushed to the head of the bed. Charcoal was bubbling from her mouth. "She's aspirating!" I told myself in horror. She was vomiting up charcoal with the seizure. Now she would breathe it down her trachea, into her lungs. This was a disaster, perhaps a deadly disaster.
"Why didn't you see this coming?" I shouted to myself. I broke open the intubation cabinet and grabbed at the equipment. The laryngoscope came first, a flat metal blade with a light attached to a large handle, and an endotracheal tube that goes down the trachea into the windpipe so the patient can be given air. You don't always need to intubate seizure patients; it's rare for the seizures to last long enough to cause a significant lack of oxygen. But this woman had a gut full of charcoal. She was only going to continue aspirating. I had to protect her airway from more charcoal. If I could get the balloon-tipped et tube in place, nothing but air would enter her airway.
But if I had anticipated that she was going to aspirate, I would have intubated her before I gave her the charcoal.
Charcoal-stained mucus bubbled up through her nose. "Set up suction," I told the respiratory therapist who had just arrived. The room was beginning to fill with people. I tried to open the patient's mouth, but the seizure had clamped it shut. We needed to stop the seizure before I could even try to intubate her. "We need Valium over here," I told Alisa. The respiratory therapist got the Ambu bag--the manual breathing apparatus--ready and was fumbling with the suction. Another nurse put the pulse oximeter on the patient's finger. This measures the amount of oxygen in the blood--96 to 100 percent is normal, anything below 90 is not good, below 80 is bad. Marilyn's reading was 90 percent.
We were "bagging," holding a face mask over the patient's nose and mouth, forcing air into the lungs by squeezing the attached oxygen-filled bag.
Alisa was back with a syringe of Valium. She drew up 5 milligrams and injected it into the IV line. We all stood watching. Nothing. Arms and legs still jerking. Jaw tight. Charcoal still bubbled through her nose. Pulse oximetry reading: 87 percent.
More Valium. Alisa injected another 5 milligrams. Nothing. Still seizing . . . 85 percent.
"What now?" Alisa said.
I had a choice. I could either try to go through the nose with the tube, pass it down into the larynx blindly and see if I could get the tube in, which was not easy. Or I could paralyze her and, when she stopped seizing, do the somewhat easier standard intubation. Which one? Decide now; 83 percent, 82 percent.
"Get some Pavulon," I told Alisa, "and some sux." Pavulon and succinylcholine produce total paralysis, making it easier to get the tube down into the trachea. But if I couldn't get her intubated, she wouldn't be able to breathe on her own. I would be stuck or, rather, the patient would be stuck. Maybe dead.
Reading: 82 percent, 82 and holding.
In a crisis, time slows to a crawl; everyone moves as if through water. Alisa finally returned with the Pavulon and sux bottles.
"Two milligrams of Pavulon," I told her. We stood bagging the patient for a moment, waiting for the Pavulon to work.
"Now the sux."
Pulse ox reading: 81 percent, 80.
The patient was still seizing--head thrown back, face contorted, arms jerking. Charcoal was everywhere.
Sux in. Pulse ox: 80 percent and holding.
Then the jerking slowed, and finally, after one last spasm, she lay still. Now her jaw opened easily in my hand. I had to get the tube through the pharynx, past the voice box, and through to the trachea. I lifted her tongue and part of the voice box out of the way with the blade of the laryngoscope. I was looking for the narrow trachea and, within it, the twin shutters of the vocal cords. "I need suction," I said. The respiratory therapist handed me a plastic tube attached to a suction unit in the wall. I tried to vacuum away the charcoal, but when I pulled the tongue aside with the laryngoscope, I still couldn't see the larynx. I readjusted the blade. Nothing. I tried again. Nothing. I couldn't get it in.
I threw the ET tube on the floor. "Get me a smaller one," I shouted. Pulse ox: 75 percent. She was not going to last long. I looked again with a smaller tube. More charcoal. "Please, dear God," I prayed. I passed the tube into the dim, charcoal-coated reaches of her pharynx. When we tried to bag her, her stomach rose and fell, not her chest. I was in the esophagus. No good. I pulled the tube out. I made another pass, roughly where I had passed it before. We reattached the Ambu bag. One breath, two. The chest rose and fell, a good sign. I listened for breathing sounds with my stethoscope. Breathing sounds. Good breathing sounds. We were in.
I called the medicine service and explained to the two internal medicine residents what had happened. She would need to go to the ICU. Diagnosis: Overdose, aspiration, seizure. They glanced at the patient and then huddled for 20 minutes with the lab reports. "Great," I thought, "they get hours to go over a decision I had to make in seconds."
The senior resident came over. "You know," he said, trying to look casual, "you probably should have intubated her before giving the charcoal."
"When she came in there was no way to predict that she was going to seize. I can't intubate every overdose I see." I turned away. Should I have known? Did I hurt my patient? I wasn't sure, and the uncertainty made me feel sick.
Finally she was taken up to the ICU. The acute room was a disaster--charcoal, blood, ET tubes, and packing material scattered all over. I stooped down and began stuffing trash into the garbage bin. I didn't think I could handle a more complicated task.
It was over.
Not quite though. Marilyn touched my life one more time. The ghosts that haunt doctors are contained in medical records. Every day minions from the medical records department comb through these charts looking for "incompletes." Signatures missing, procure notes absent, discharge summaries never dictated. All these missing pieces are tagged for the doctor to complete, sign, or dictate.
I was working my way through the stack of charts one evening when I found myself opening Marilyn's. Six months had passed since I'd seen her. I felt a rush of nausea. The charcoal, the charcoal, I thought again. Should I have known she was going to aspirate? Then the nausea subsided and I started paging slowly through the chart.
She arrived in the ICU and immediately went into ARDS--adult respiratory distress syndrome--a toxic reaction involving the lungs. Then she became septic--big-time septic, the medicine service thought anyway. She was started on three antibiotics but kept spiking fevers through them. Nobody knew why. Then one of the antibiotics damaged her kidneys so much they almost shut down completely. She was on kidney dialysis for weeks.
At last things evened out. Her kidney function returned. Her lungs cleared up. The team transferred her out of the ICU six weeks after she was admitted. There was another setback, though, a small stroke. She ended up in the hospital rehabilitation unit and was discharged only a few days ago. Hence the chart for my signature.
The weird thing, though, was that after my initial er dictation, nowhere in the chart did anyone note Marilyn's drug problem. As far as I could tell, the suicide attempt was addressed by having a psychiatrist visit her once for 20 minutes. His consult note said she was no longer suicidal; she was depressed secondary to problems in her marriage and would benefit from marital counseling. Nothing about all the drugs. Nothing about the massive amount of painkillers and sedatives she required during her stay. The doctors had saved Marilyn's lungs, her kidneys, her guts, and her brain, but they had ignored her addiction, the problem that had brought her here.
The last progress note in the chart stated that Marilyn was now off dialysis, tolerating an advanced diet, and able to ambulate without assistance. Vital signs stable. Patient discharged in good condition. Sent for follow-up to her primary physician.
Referred to Dr. Daiquiri.
