By Birdstrike MD
The radio crackles alive, “County General…we’ve got a 20-something female……just picked her up…..bagging….we’re at your back door…”
Boom! They slam through the double doors, and roll into room 8. Lying on the stretcher is a young thin woman. Beneath the mask over her face is a full head of golden wavy hair. I get to the head of the bed, and get ready to intubate her. I grab the bag and mask and start bagging her myself. “What have you given her, so far? Any narcan? D50?” I ask.
“No,” the paramedic says. “We just scooped her up and had just enough time to get her here and pop an IV in. Just lost pulses a few seconds ago. PEA.”
“Okay, give her some narcan and D50, while I get ready to intubate. Resume compressions! Etomidate, sux, scope…” roll off my tongue. I look down at the patient’s face again……blond, so young, hair and face like a movie star, except for the pale-bluish dying hue. She reminds me of Cat Woman from the old Batman comics. She’s just about dead and much too young to die. I don’t think I can handle another young patient death this week. I’m filling with dread, not from anything that has to do with the medical “case” in front of me, but because somewhere out there is an unsuspecting mother, husband or child that I’m going to have to tell that she is dead. There’s no way to candy-coat that news, and no matter how many times I do it, it still gives me chills.
The nurse has just given narcan. She starts to move. Is she trying to breath? I look at her face, it’s pinking up. Did we restrain her before the narcan? Damnit….we didn’t!
She VIOLENTLY sits up, blasting upwards towards my head, ripping the mask off her face, ripping out her IV and heaves forward. I’m looking straight at the back of her head and torso and she’s heaving forward violently grabbing at her own neck, making an awful guttural noise, contracting rhythmically. That noise, what’s that noise? I’m hearing my cat, she’s trying to vomit. Is this lady trying to gag up a hairball? Cat Lady.
I look beyond her and the nurses are staring back mortified, at the patient. “Ahhhhhh! Ahhhhhhh! Ahhhhhh!” this Cat Lady is screaming. “I’m dying here! Help me!!! Oh, the pain, s—t, the pain!!!”
I step around out from the head of the bed to the front of the patient to see what the nurses are looking at, and on the patient’s lap is a big, gooey, mucous-covered ball of something on her lap. Whatever it is, this patient was choking on it, it almost killed her and now she’s alive and well, though ready for vengeance. Why the heck is she screaming, now? This thing, whatever it is, is out of her, and she’s awoken from the dead.
I pick up the ball of goo and examine it. I start picking it apart. Why do I have to do this, this is disgusting? I should’ve been an accountant. Hairball, I think to myself, laughing a little bit inside. Just like my cat. It seems like a ball of wadded up plastic. What the heck is this thing? There’s writing on the plastic. What is it?
Is that an “F—–, Fe—“?
“Fentanyl! Fentanyl!” yells one of the nurses looking over my shoulder, who can obviously read through bloody mucous much better than me. Fentanyl patches. It’s a big wadded up ball of too many fentanyl patches to count.
“I’m in pain!! Help me, I’m in F—–G PAIN!!!!” screams Cat Lady, who’s looking much more like the Wicked Witch of the West now, than the sultry cat woman of past comic books.
It all makes sense now. “Did you eat fentanyl patches? Why did you do that? What else did you take? Were you trying to kill yourself? Were you trying to get high? What happened?” I ask her.
“F- you, Doctor, or whatever you call yourself. Give me something for pain, NOW!” she demands.
“More of what almost just killed you? Absolutely not. If you want us to help you, tell us what happened. This is not a joke. You came seconds from dying. What happened?” I ask.
“I have no idea. I don’t remember a damn thing,” she says.
“Where did you get the patches? Are they yours, did your doctor prescribe them to you? Did you buy them on the street?” I ask.
“None of the above. Please, I’m begging you. Give me something for pain, anything. Please,” she begs.
“I can’t do that. In a few minutes the narcan we gave you will be wearing off. You’re likely to have plenty of pain medication still in your system at that point, and this withdrawal will wear off. You may have enough opiates in you to slip back into a coma again. You might need a narcan drip. We’ll just have to see,” I try to explain to her.
“Then let me out of here. Now! I’m signing out AMA. I’ve done it before. Give me the papers!” she demands.
“I cannot do that. As far as I am concerned, you tried to kill yourself, or at the very least, your judgment is still clouded by an overdose of pain medicine. You’re not going anywhere. It’s my job to hold you here until either you’re out of danger, or at least sober enough to make a rational decision,” I explain.
I walk out of the room. By this time, security is already at the door, and there is no way she’s getting out of here. I go back to my desk, to think this through. This patient is not going to be easy. She’s demanding to leave, which I cannot allow if she’s suicidal. If this was accidental, and she still insists upon leaving, I at least need to know all of what is in her system. I also need to know when it is fully out of her system before I can be sure that she’s clinically sober and able to make a rational decision, if she’s going to refuse care. The best thing is to get her admitted.
A few minutes pass by and she’s much calmer. We keep her on a cardiac monitor, on some oxygen and watch her. She agrees to have some labs drawn and a urine sample. As the narcan wears off, she drifts off to sleep, but her vitals remain normal. I call the hospitalist to admit her. A few minutes later, off she goes to her room. The rest my shift goes uneventfully, if that’s even possible for an ER shift.
A few days later, Dr. Goodwin, the one who admitted her is down in the ED again. I ask him, “How did that lady do, the one who almost choked to death on the fentanyl patches?”
“Oh, yeah, how could I forget? She slept it off, sobered up and signed out AMA. Psych saw her and agreed she was no longer intoxicated and was competent to make that decision. She never even needed another dose of narcan. She wouldn’t tell anyone anything about anything. She denied being suicidal, denied having any drug problem, and refused a referral for either substance abuse help or psychiatry. But, get this: before she left, she demanded I give her cash,” he chuckled out loud. “Cash! Can you believe that?”
“She hit you up for cash? Really?” I ask. “I suppose there was no, ‘Thanks, you’re the best doctor in the world’ to go with it?”
“Uh, no. She told me I was ‘ruining her life.’ I suppose she didn’t run down to the ER and tell you, ‘Thanks, for saving my life, Doc!’” says Dr. Goodwin, with a cynical and jaded smirk.
“Are you kidding? Uh…no,” I answer.
“I figured not. She told me she was reporting all of us to the State Medical Board and getting a lawyer to sue us and the hospital out of business. Yeah, you should have seen her, man. She ran out of here like she was on fire. She sure was in a hurry. Said she had somebody real important she had to meet up with.”
This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient, real person, real co-workers or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that they are fictional, and certainly HIPAA compliant. Artistic license can and will be used liberally as needed. If you want boring scientific cases presentations, read a peer reviewed journal. Any opinions expressed here are of the author alone and not those of Dr. WhiteCoat, my employer or any of the hospitals with which I am affiliated.