Monday, 7 November 2016

Pure idiocy

In case you haven't noticed, recently I've tried getting away from calling my patients "idiots".  I've been trying my damndest to keep in mind that everyone makes mistakes and some people even have reasonable reasons for those mistakes.  People don't deserve to be crucified for doing stupid things, right?  Right, they simply need to be educated.  Jumping to calling people names is childish and silly (not to mention very judgmental), and I think of myself as better than that.  Call it the New And Improved Insult-Free DocBastard!

Having said that, Erin (not her real name™) is a fucking idiot.

I have never done illegal drugs in my life.  I've never felt the urge and I've never given into peer pressure, though I've been around many people who have.  I've never really understood why anyone would want to allow himself to be out of control of one's senses and/or body parts.  It just doesn't look like a good time.  Erin, on the other hand, got herself into heroin at a very young age.  At just 23, she had been in rehab twice already and was taking buprenorphine, an oral medication similar to methadone, to try to stay off heroin.

It wasn't working.  At all. 

One gloriously stupid evening 25-ish year old Erin stupidly decided that, in addition to taking her buprenorphine, she would also stupidly inject herself with heroin.  To add to the steaming, stinking stack of stupid, she then got in her car and drove . . . somewhere.  She apparently had no idea where she was going, because several minutes later she found herself in the middle of nowhere with her car wrapped around a tree.

Well, I shouldn't really say "she found herself", because she was completely unconscious and in no position to find much of anything except the inside of a morgue.  When the medics found her she was slumped over in the passenger seat next to a half-empty liquor bottle (and no, of course she wasn't wearing her seat belt).  They recognised the telltale track marks on her arm and rightly gave her a dose of naloxone to counteract the heroin they (correctly) suspected she had taken.  Normally patients who have overdosed on narcotics wake up immediately after being administered naloxone and are very angry that someone killed their high.  But not Erin.  She woke up only minimally because in addition to being high as a fucking kite, she was also drunk as a Tyrion Lannister (I greatly prefer him to skunks).

Fortunately for Erin (and unfortunately for me), she woke up a bit more on the ambulance ride to me, because when the medics oozed her into my trauma bay, she was fully awake.  And screaming.  Screaming at everyone and everything.  I've never been so angry that I've yelled at a complete stranger who was trying to take care of me, but that was exactly what Erin did, in addition to yelling at the floor, oxygen mask, and cervical collar.

"GET ME THE FUCK OUT OF HERE!  AAAAAH!  GET OFF OF ME!  AAAAAAAH!"

Sigh.  Just another Tuesday night.

My initial survey revealed a few abrasions here and there and a chronic-appearing ulcer on her leg, which looked suspiciously (read: obviously) like a former (or current) heroin injection site.  Of course I never found out because she refused to tell me anything.  When I got to her abdomen, she seemed to wince a bit when I pushed on her left side.

In the trauma world, that's an injured spleen until proven otherwise.

Unfortunately she wouldn't allow me to perform an ultrasound to see if she had blood around her spleen.  Her refrain of "GET THE HELL AWAY FROM ME!" kept ringing out, loud and clear.  After about 30 minutes she finally calmed down (i.e. sobered up) to the point where, instead of screaming at us, she was simply saying "Get away from me" in a calm (though rude) voice.

After much begging and cajoling, we finally convinced her to allow us to perform a CT scan of her abdomen, which continued to hurt rather significantly (though she wouldn't allow anyone to re-examine her).  If you've been reading this blog for any period of time, you can probably predict the outcome of the scan:

Actually, no you probably can't, because I enjoy fiddling with people.  You see, unlike most of the patients I write about, this one WASN'T uninjured.  She had a very nice laceration of her spleen (SURPRISE!) with a significant amount of blood around it.  An injury that severe doesn't usually require surgery, since the bleeding typically stops on its own).  But it does require close monitoring in hospital, preferably intensive care, with frequent blood draws to make sure that the bleeding actually stops (which it does about 90% of the time).

As I walked back to the trauma bay to give her the wonderful news, I thought about just how lovely and fun the next week or so of rounding would be, knowing that she would be a model patient: polite, cooperative, and pleasant to care for.  I probably had a visible scowl on my face when I walked in, but that scowl quickly changed to a gape. 

Erin was getting dressed.

The nurses were trying to calm her and get her to sit back down on the bed, but Erin was having none of it.  "I'm getting the hell OUT of here!"  I calmly and rationally (read: quickly and loudly) explained that she had a very serious injury and she had to stay here.  With me.  Oh, the joy.

"The hell I do!  I need to go home so I can smoke.  BYE!"

I again explained about her injury, why she should stay, and would could happen if she left.  If her spleen continued to bleed, she could easily bleed to death.  She listened, paused, and then demanded to see the papers she had to sign to leave against medical advice.  She also insisted that we not tell anything about her injury (or her drug use) to her father, who had apparently just arrived to see her.  Obviously she had been in this situation before, because she knew all the things to say that prevented us from caring for her in any way.  When her father walked in, she simply told him "I'm fine, dad.  Let's go."

And two minutes later, she was gone like Keyser Söze.

I have no doubt that Erin has pulled this shit before, and I have even less doubt that she will do it again, assuming her splenic laceration didn't kill her.  With her luck, she probably healed up just fine and went back to doing heroin the next day. 

Since as you know I'm a hopeless optimist and always try to see the good side of every story, here is the silver lining of this story: Erin lives well over 2 hours away from me, so the chance of her driving high and drunk again and encountering my wife driving my children around town is very close to zero.

But it is not zero.  And that scares the shit out of me.

34 comments:

  1. (which is does about 90% of the time)
    Just a little typo for you to fix in case you didn't see it up there

    -dimerneckel

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  2. She's lucky she didn't get arrested. Rule of thumb for heroin addicts in the ER. Sign AMA form right away before cops shows up.

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    1. doesn't work where I am from. the cops tend to ride in the ambulance with the addict.

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  3. Doc, how would you handle drunk doctors coming in at 2200 on a Friday night making rounds on their patients in the hospital? This doctor in question is in a higher position of authority. How would you intervene if you're the lowest man on the totem pole?

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    Replies
    1. Go to the chief of staff. If he is chief of staff, go to the hospital president.

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  4. this is why the paramedics I cross paths with tend to try to use just enough to get the overdoser breathing on its own, but not enough to actually wake them up enough to put up a fight.

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  5. Your correct about applying the idiot name. One of these days she will win the Darwin Award for her activities.

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  6. To me this sounds like a suicide attempt. Overdose and run a car into a tree. Rings with the 'panic' and screaming she showed afterwards, as a way of venting her desperation that she survived, maybe? It can be depressing to realise how deeply you are trapped in the claws of addiction.
    Anyhow, all is purely speculative.
    Attempting suicide by endangering everyone else on the streets is really unfair! To say the least ...

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    Replies
    1. I have it on good authority that the behavior I have seen after opiate overdoses are cancelled out is pretty consistent for all opiate cancellations. - and this is consistent with that.

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    2. Thanks Ken Brown! There's nothing like first-hand experience :).

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  7. Why would anyone take heroin and then just go to sleep? What kind of high is that? Shaking my head.

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    Replies
    1. because that is what large doses of opiates do to you.

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    2. To sleep? You can take over the counter benadryl for that.

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    3. Benadryl doesn't work for everyone--I'm one of those people. If you give me benadryl it just....does nothing. Unless I happen to be having an allergic reaction to a med, which has happened before.

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    4. comprehension problems, anon? if you take too much opiate, you pass out. if you take way too much, you pass out and stop breathing.

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    5. You can now buy narcan without prescription. CVS started the program years ago.

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    6. in some places. not in others.

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  8. I knew someone that was a recovering heroin addict, and had hepatitis C. Died from liver failure. This guy was in 50's. Young people I guess don't think of the damage it does to your body, if they even live till they are older.

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  9. The heroin she shot would have been blocked by the buprenorphine. The naloxone didn't work so good because there was no heroin on her receptors. Only buprenorphine which mostly does not get unbloked from the naloxone. Which was why she was severely in withdrawl. Believe me I know. 30 year junkie here.

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    Replies
    1. Heroin vs buprenorphine overdose. I'd go with heroin since she responded immediately after narcan. If this was buprenorphine overdose she would not have responded to narcan right away.

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  10. calling erin an idiot doesn't help. her choices are not idiotic for someone who must have drugs to avoid feeling horrible. sadly, they gave her the drug to get out of the heroin coma. I don't understand the point. The paramedics had no proof that she had overdosed on drugs. Why save Erin?

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    Replies
    1. Calling out people on their idiocy DOES help, and I do it regularly to their faces. If they don't understand what they did was stupid and almost killed them, they are likely to do it again.

      The medics correctly suspected she had used heroin (remember the telltale track marks I mentioned?). Saving people is what they do.

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    2. the choice to sedate yourself and then DRIVE A CAR is ALWAYS idiotic.

      emergency responders don't judge who is worthy of saving and who is not. we respect when someone has filed paperwork that states they want to be left dead when they die, but other than that, we save all of the people we can save. even in a triage situation, our strategy is to save the most people we can save without regard to the person's worth.

      and yes, there are circumstances where calling out the idiot improves their behavior enough to facilitate saving them.

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    3. The majority of heroin addicts will not dare drive a car after doing heroin. They are isolationists. They prefer to do heroin in a place where they feel comfortable preferably away from the public's eye. This means NO driving. You might might find them inside their cars and passed out but you won't find them driving. The crazy ones driving are the tweekers, coke heads, and alcoholics. This is why Erin's case is rare.

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  11. When I read your first paragraph, a paraphrase of a Bryan Stevenson quote popped into my mind:

    Each of us is more than the most idiotic thing we’ve ever done.

    If you need help moving away from the term "idiot" or "idiotic" maybe that will help you remember that you have a whole person in your ER, not just one event sitting there. (I know that you know this; it fuels your compassion.) But maybe this quote will help focus your mind when the next one comes through the doors.

    (The actual Stevenson quote was about mercy and the justice system: "Each of us is more than the worst thing we’ve ever done." and he was trying to get people to show mercy even to people convicted of serious crime. But the same principle can apply to people acting in idiotic ways.)

    Joshua

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    1. That may be, but I imagine trauma surgeons carry a bigger burden than the rest of us given that they also see the victims of drunk or drugged drivers. I think I can forgive the struggle to be compassionate. I can even forgive the choice not to be under those circumstances. After all, they're only human.

      As far as I'm concerned, if someone wants to refuse treatment--even if it may kill them--then that's their choice and I'd hardly criticize it. I'll save my criticism for when they put innocent people at risk.

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  12. Had to delete my last one, there is no edit button..

    My guys would have been on the rotation to scrape this idiots victims out of their car(s).. Thankfully there were no victims..

    As a counselor for 15+ years, I also have degrees in criminal justice and psychology, I understand the sadness and complications from addiction..

    However, I work on the opposite side as a dispatcher now and see how it annihilates families, whether it's theirs or a strangers..

    In the last week I had to send one of mine to a single car accident- drunk asshole hit pregnant woman, mom and baby died.. I sent a woman, my heart broke when she came in to the office in tears and shock..

    Sent one of mine out to a bad accident with one of my office staff, had no idea they were working on one of the occupants of the two cars, traumatized the hell out of my staff when they got on scene and the guy died.. and, right after they left that scene they watched a three car accident a block away, the drunk driver was up walking around, the guy he t-boned had the plastic of his door shoved threw his thigh and had blood arching with every heart beat, and the other driver was nonresponsive with no pulse.. and with that trifecta I figured I lost my new office staff when she got to the office sobbing, puking, hyperventilating, and in shock..

    Never a dull moment, thankfully I get the brunt of the weekend madness with two 14 hour shifts and a 12 and 4 days off to forget there is anyone on this earth besides my teenagers..

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    Replies
    1. it tends to be car crashes that make our responders decide this is not for them. the worst is when the victim is somebody they know.

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    2. I'll never forget being a witness to a fatal car crash where two people died and one was ejected out of the window (female) after it swerved to hit another vehicle. They ended up hitting the side of building. I heard them scream but after that complete silence. I was frozen and didn't know what to do. However, I did call 911.

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    3. calling 911 is what we want.

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    4. Can you apply for PTSD disability for that?

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  13. Good Lord. I had a spleen laceration in college (after performing the phenomenally stupid attempt to climb into my loft via the tv balanced on my roommate's desk, which tipped over and deposited my ribcage onto a 4x4 bedpost. Unlike Erin, I do not have the excuse of insobriety.) I still remember the breathtaking pain of that experience, having to crawl into the hallway to flag down a friend and beg to be taken to the ER. I spent two days in ICU on a morphine drip and it was three months before I could take a deep breath without any pain. How does ANYbody just walk out of the hospital in that condition?

    I probably shouldn't ask sensible questions about people with Erin's disposition though.

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