Chapter 65: You'll Just Have to Wait to Find Out!

December 19, 1988, McKinley, Ohio

"If that deputy wasn't pissed at you before, he's going to be livid now," Felicity said when we left Larry's room.

"Let him be pissed," I replied. "What is our sole obligation?"

"The treatment of the patient. Even if he beat up his girlfriend."

"Exactly. Let the cops worry about themselves. Maybe the kid comes from money, and can afford a lawyer, but I'll start with the Public Defender's office."

"I think you don't get your attorney until you're arraigned and the judge grants you a public defender."

"I've never been arrested, so I couldn't tell you. I'm pretty sure their office opens at 9:00am when the Courthouse opens, so I'll wait until then. The deputy can't do anything until we release the kid, anyway. And I'm betting he simply fills out the paperwork to have us release the kid to his custody when it's time to discharge him. I honestly doubt he's going to hang around for a kid who was high on ecstasy."

"And beat up his girlfriend."

"Allegedly," I replied. "We don't know any details, and it's not our job to know, even if it bothers me personally."

"Maybe he was dealing?"

I shrugged, "Same thing, from our perspective. All we know, and the only thing that matters, is that the kid has molly in his system and is showing arrhythmias. Nothing else matters — not even if he hit his girlfriend or was dealing drugs. We treat him the way we treat any other patient. And, to make my point, I had to treat the guy who murdered my friend."

"What the fu...?! Sorry. What the heck?!"

I chuckled, "I have heard that word before and have used it more than once. If you've heard about the guy who was intentionally run down by a local religious fanatic, it was my friend who died. Sometime later, while the driver was in jail, somebody took exception and beat the crap out of him. He was brought into the ED while I was there, and I helped treat him. He was sent to the locked ward because he was an actual convicted felon who was in jail, and wasn't showing any cardiac anomalies."

"Where is that ward?"

"It's the same one Psych uses," I replied. "When the new surgical wing is built, they'll create a second locked ward in Medicine, because they'll take over much of the old surgical area, but that's almost a decade away. The new ED wing is set for completion about six years from now, and that's the first stage. Once that's done, the new surgical wing will be built, and it's due for completion in about nine years. It's also possible those dates could move up, because things are moving more quickly than the original plan."

We went back to the lounge so Felicity could eat her breakfast, and at 9:00am I called the courthouse. I was told by an Assistant Public Defender that they couldn't see Larry until he was brought before a judge, which wouldn't happen until after he was released from the hospital. They would have someone in the courtroom for Larry's arraignment, which was their normal procedure, and matched what Felicity had told me. I left the lounge to let Larry know and encountered the Deputy outside Larry's room. He gave me an evil eye, but I ignored him and went in.

"Did anyone call your parents?" I asked.

"Someone in the ER did, but I doubt they'll show up. I'm not living at home."

"The Public Defender's office said they'll have someone in court for your arraignment, and suggested you speak to a private attorney if you can afford one, and not speak to the police under any circumstances."

"That last bit I got down," he said.

"You've been arrested before?"

"By the same cop," he said.

"OK, well, my sole advice to you is to tell Psych you want to get off the molly and they'll put you on a seventy-two-hour hold. I'd advise you to take advantage of that because, looking at your EKG and BP, you're on your way to a heart attack or stroke if you don't stop."

"That bad?"

"I've seen eighty-year-olds who have hearts in better shape than yours."

"You a new doc?"

"Sub-Intern," I replied. "Some people call the position 'student doctor', but I can't call myself a doctor until I pass a test in May. I've completed three-and-a-half years of medical school."

"So they let you do all the stuff you did before?"

"Student nurses are allowed to do that and they mostly don't have undergraduate degrees and have only one year of academic instruction."

"But you can read the EKG machine?"

"Yes. The monitor is clear at the moment, but right after they brought you up, I could see SVTs, or supraventricular tachycardia. Once your body metabolizes the MDMA, they should go away completely. I take it you felt your chest pounding, were short of breath, dizzy, and possibly sick to your stomach?"

"Yeah. I felt like I was going to pass out."

"Those are all symptoms of SVT," I replied. "And that's one side effect of molly. Did you take anything else?"

"You won't tell the cop?"

"No. The tox screen will likely show it, though, and there are ways for the cops to get those. You were under arrest, so I'm pretty sure the County Prosecutor will get a look at the lab report at some point."

"Shit."

"What did you take?"

"Ritalin on Friday and Saturday night."

"Do you have a prescription?"

"Yeah, right! I copped them from a kid at school with ADHD 'cause I couldn't get molly from my regular guy 'cause he was busted last week."

"And you were jonesing for a hit, right?"

"Yeah."

"You're a regular user?"

"Yeah, man."

"And you're taking bigger doses now than before, right?"

"How did you know?"

"Your body develops a tolerance for amphetamines, so you have to take more to get the same effect, and you can go into withdrawal in less than twenty-four hours. There is no specific medical treatment, except what we call 'palliative' or 'supportive' which means we treat symptoms. The only way out is through counseling and therapy. The next few days are going to really suck, and if I were you, I'd want to spend them here rather than the county lockup. Just tell the Psych Resident you want to quit. If you don't, they'll kick you as soon as your blood pressure comes down thirty points and you don't show any signs of an irregular heartbeat for twelve hours. You'll go through withdrawal one way or the other."

"Can I ask why you give a fuck?"

"I believe the oath I took, and that means helping anyone who presents, that is, shows up at the hospital, to the best of my abilities. Your legal troubles are, for me, beside the point, and have no bearing on my willingness to help you. I'm limited in what I can do, but I can give you advice, so long as it's not a diagnosis. My best advice is to get clean, graduate from High School, then either go to college or find a vocation."

"Are you going to be a heart doctor?"

"A cardiologist? No. I plan to be a trauma surgeon, that's a doctor who works in what you call the ER and who is trained to do emergency surgery as well as the usual things done in the ER. I'm doing a cardiology rotation because I need some basic knowledge about it to properly treat and diagnose patients in the ER."

"You seem like the only one who gives a shit."

"The doctors, nurses, and others in the Emergency Department have one job — to keep you alive and stabilize you, then hand you off to another service. They don't do much more than that because they don't have time. You arrived this morning at a busy time for us, because two doctors are performing surgery, and that leaves just one doctor and two medical students to handle the rest of the patients, and we have other duties as well. The nurses are also busy."

"So, what are you blowing off to be here with me?"

"Nothing at the moment, but my pager could go off at any..."

My pager went off just then and showed a code notification and room number.

" ... moment. I need to go. I'll be back."

I left and headed for Internal Medicine, meeting Doctor Javadi in the corridor by the stairs which we took down to the second floor, then moved quickly along the corridor to the room where James, a Fourth Year, was doing CPR and a nurse was bagging a patient, while Doctor Peters, a Resident, was setting up the defibrillator.

"Fifty-five-year-old male, post cholecystectomy," the Resident said.

"Run it, Mike," Doctor Javadi ordered.

I looked at the monitor and saw obvious signs of arrhythmia that I recognized.

"Pulseless V-Tach!" I declared. "Wide QRS and Josephson's sign!"

"Agreed," Doctor Javadi said, looking over my shoulder.

"Charge to 200," I said to Doctor Peters.

He set the controls and pressed the button to charge the defibrillator while I moved into position and picked up the paddles.

"Halt CPR and clear!" I ordered.

Both James and the nurse stepped back, and I put the paddles in the correct locations and pushed the button. The patient spasmed from the jolt of electricity, but nothing changed on the monitor. I felt for a pulse and felt nothing.

"Charge to 200 again!" I ordered.

We repeated the cycle and nothing changed on the monitor.

"Resume CPR," I said. "High-dose epi!"

Doctor Javadi administered the epi via the IV and per protocol, I waited for 30 seconds to allow the CPR to circulate the drug in the patient's system.

"Charge to 200!" I declared.

The machine whirred and beeped.

"Clear!" I declared.

Everyone moved, and I administered the third shock.

"No cardioversion," I replied. "Resume CPR."

James and the nurse resumed CPR, and about fifteen seconds later, the monitor squealed and flatlined.

"Asystole!" I declared. "Epi! Continue CPR!"

Doctor Javadi gave a second dose of epinephrine, and nothing changed after a minute.

"Halt CPR!" I ordered.

They did, and I listened for any heart sounds and checked for pulse, and found neither, then checked the patient's eyes and found the pupils to be fixed and dilated. Not being a doctor, I couldn't make the call, so I shook my head and looked to Doctor Javadi. She stepped close and repeated the exams.

"Two doses of epi in," she said. "No heart sounds; no pulse; no shockable rhythm; pupils fixed and dilated. Time of death, 09:41."

"Chart, please, Doctor Peters," I requested.

He handed me the chart, and I made the proper notations from my exam, then handed the chart to Doctor Javadi to sign, which she did. When she handed it back, I took a moment to look through it, then handed it back to Doctor Peters. It was his case, so Doctor Javadi and I left the room to head back to cardiology.

"What did you see on the chart?" she asked.

"A train wreck," I replied. "Post-surgical; history of hypertension and hypercholesterolemia; smoker; obese. Any of those are risk factors for thromboembolism, so I'll bet you a subsidized lunch that's what Doctor McKnight finds, either in the brain or heart."

"I'd say that's a strong possibility and would be the first thing I'd look for," Doctor Javadi said. "You did a good job running the code."

"Thanks. Is there anything you would have done differently?"

"I might have bumped to 250 for the third shock, but it wouldn't have mattered. 200 is nearly always sufficient for cardioversion. That said, with an obese patient, higher charge levels are sometimes necessary."

"Did I screw up?" I asked.

"No. The patient was dead before we arrived; his body just didn't know it. You shocked him three times, with sufficient charge."

"So, next time, go to 250 on an obese patient?"

"That would be my choice for the third shock, but again, 200 is textbook, and what Doctor Strong does. If it's going to work, that'll do it in nearly every case. You did everything right according to your training and your textbooks. When McKnight does the autopsy, I'm confident he'll confirm that there was no point in continuing to flog the patient."

"Did you call for a Psych consult for the MDMA patient?"

"Yes."

"I suggested he tell the Resident he wants to quit. That'll give him at least three days of withdrawal here before they lock him up."

"Bleeding heart?" Doctor Javadi asked with a smile.

"I sure as heck wouldn't want to go through withdrawal in lockup. Somehow I think the Nurse-Practitioner in the jail infirmary will be far less sympathetic than Internal Medicine and Psych here will be."

"I'm sure you're right, and I agree. The 'bad guys' need our help as much as the 'good guys' and we don't make moral judgments when it comes to providing treatment."

"We also don't know for sure what happened, and we can't really ask, as much as I wanted to."

"No, we can't, and please don't. You know the policy."

"Yes, if the patient volunteers the information, we can listen, but we should try to avoid discussions about potentially criminal acts because we can be subpoenaed and Miranda doesn't apply to things said to us, and 'confidentiality' can be deemed waived by a judge. Speaking of which, Larry did tell me he took Ritalin several times last week after his source for MDMA was arrested."

"He has a script?"

"No. He obtained them from a student at the High School with ADHD."

"Did you write that on the chart?"

"I had only discovered it just before my pager went off. I'm sure the complete tox screen will show it when it comes back, so I'll wait for that, then make the notation, if that's OK."

"Probably better," Doctor Javadi said. "The last thing you want is that deputy grilling you. Just verify with him when he took the Ritalin and leave it at that. Don't note that it wasn't prescribed. Let Psych deal with that."

"Will do."

When we returned to Cardiology, we, along with Felicity, joined Doctor Getty, Doctor Strong, and Doctor Pace for rounds. There was nothing of note, and no discharges, so when rounds were completed, we returned to the lounge. About fifteen minutes later, Steph let me know that the tox screen for Larry was ready. I sent Felicity to the lab to get it, and when she returned, I scanned it, and it was worse than I'd thought.

"Ritalin, MDMA, and positive for metabolites for methamphetamine," I replied. "Not to mention nicotine and high levels of caffeine. He's lucky it was just runs of SVT."

"Why take so many different uppers?"

"Amphetamine tolerance," I replied. "He needs a bigger hit to get the same high, and he told me he couldn't get MDMA from his usual source. I'm guessing he took Ritalin, and chugged Mountain Dew or crushed Nō-Dōz and possibly even snorted it."

"Wait! Seriously? Snort Nō-Dōz?"

"Yes. A Nō-Dōz tablet contains 200mg of caffeine, or about the equivalent of a cup of coffee; snorted, the effect is far faster than via the usual oral route."

"Weird."

"You haven't seen anything yet," I chuckled.

"Oh?"

"You'll see during your trauma rotation. My favorite so far, though it's not anything too weird, was retrieving a 'lost' condom."

"Lost?"

"He allowed himself to go soft before withdrawing and the condom was retained by friction. I removed it using a speculum and forceps. The poor couple then had to worry about pregnancy because it had, obviously, spilled semen into her vagina."

"And that's not weird?"

"Compared to the lost vibrator? In a guy?"

"OK, never mind!" Felicity exclaimed. "I think I'll stick to oncology!"

I chuckled and nodded, "Let's go update the chart."

We went to the nurses' station, and I clipped the report onto the chart, made some notations, signed it, then handed it back to the nurse. Once I'd done that, I went to the Resident's office to inform Doctor Javadi.

"Positive for MDMA, Ritalin, methamphetamine metabolites, caffeine, and nicotine. I'd say in non-cardiology terms, he's lucky his heart hasn't exploded."

"Bodies will take a lot of punishment at seventeen," Doctor Javadi said. "Until they don't."

"I updated the chart, but didn't speak to Larry."

"Psych is on their way down."

"OK if I sit in?"

"If there's nothing else you need to do. Take Felicity with you."

"Will do."

We went to the corridor outside Larry's room and about two minutes later, Doctor Silver from Psych arrived, carrying Larry's chart, and accompanied by Lisa Moore, a Third Year I knew by sight only. The four of us walked past the scowling deputy, and I closed the door to the room behind us for privacy.

"Hi, Larry," Doctor Silver said. "I'm Leah. This is Lisa, and I believe you know Mike and Felicity."

"You're the headshrinker?" he asked.

"So called," Doctor Silver said with a smile. "I've reviewed your chart, and we found MDMA, Ritalin, methamphetamine metabolites, caffeine, and nicotine in your system. Is that a normal Monday morning for you?"

"Pretty much," Larry admitted.

Larry was, in my mind, surprisingly cooperative, though I wondered how much of that was him using the strategy I suggested and how much was real. In the end, I didn't care, because he'd be treated far better in the hospital than in the jail infirmary. And it wasn't as if we were preventing the government from pressing charges. Of course, once Doctor Silver decided to accept Larry and put him on a seventy-two hour hold, he'd be moved to the locked ward, but again, that was better than the jail infirmary.

"Mike, Felicity, let's step out," Doctor Silver said.

We left the room and moved down the corridor away from the deputy.

"I'll take him," Doctor Silver said. "I'm suspicious about him being so cooperative."

"That might be my fault," I admitted. "I suggested he'd be better off going through amphetamine withdrawal here rather than in jail, and he could do that by telling you he wanted to get off the drugs."