The "Indian-Giver" & "Itty-Bitty" Laws

The Indian-Giver Law
When administering medication via any route (i.e., oral pills or tablets, injection, suppository, patch, other) always remember: "Once a medication has been given to the patient, it is difficult (if not impossible) to get it back."

The Itty-Bitty Law
Therefore, one should always be guided by the Itty-Bitty Law:
"Always start with an itty-bitty dose, especially of any new medication, because you can always give more, but (see Indian-Giver Law above)."

Corollary of the Itty-Bitty Law
"Just because they make a specific dose size (e.g., a 25- or 50- or 100-mg pill), doesn't mean you have to give that much to a patient."

(see "Appropriate Dose" posting on this blog; see Also: "That's Why God Gave Us Pill Cutters"

"Lazarus! Come Back!" ( and he did ! )

In a sane world, it was going to be an insane night.  The signs were everywhere.  The relentless, driving wind was buffeting the building like a summer storm, it blustered and it blew, but no rain fell.  Where was the rain I sensed was on the way?  The "mid-day"-level moon glow made landing lights  unnecessary on the hospital heliport.  What time was it, really?  1:01 am.

"Oh, God!  Another night on call and I can't sleep.  I'm not even getting calls to keep me up.  Someone!  Please!  Call me with a problem so I have reason to be conscious."

Want to know how to make the phone ring?  Put your head down on the pillow and actually doze off.  It works every time.  Just like getting in the shower or sitting on the pot.

"I'm well acquainted with the way the nurses do it.  They sit at a south-facing window on the fourth floor and watch the Call Room curtains for 'lights out,' then wait 10 minutes and start dialing the phone."

I pulled the pillow under my sore left shoulder, wiggled and Jiggled and adjusted the covers, inserted ear plugs to block out the laughter coming through the tissue paper wall between the nurses lounge and my call room.

"Damn!  The wind, the noise.  I'm beat, why can't I sleep?" Who the hell are you talking to?  I'm aware you can't sleep.

Who's here besides you and me anyway?  I AM paying attention, you know.

"So what do I do now?"

Resign yourself, Insomniac: pace the hospital corridors and count sleeping patients.

"Damn them!  Why do they get the sleeping pills when I'm the one who needs the rest?"

You could go raise hell on all the wards and wake the patients up.

"Don't tempt me.  I'm close to something wacky like that now. "

The voices in my head customarily began after 24-plus hours on emergency call, like it was a job they had to do.  They couldn't be stopped.  Who wanted them to anyway?  They were the only company I had during the 60 hour Friday-night-to-Monday-morning stretch as the only doctor in the house:

If you're going to leave the Call Room, put on a clean scrub suit.  The one you're sleeping in has blood on the leg from the last IV you started.  My hands flew up to cover my ears, fingers straight up, curving slightly to allow the nails to dig microscopic trenches in my scalp.

"Shut up, just shut up, would you please.  Goddam, I wish I knew if I should take more medicine or stop it altogether!"

I found some old, clean scrubs, velvety from being washed for years in boiling water, pulled them on and reached, without looking, behind the door for my white lab coat.  After fifteen years of weekend confinement in this isolation cell there were certain things I didn't have to look for, they were at my finger tips, where they always were when I reached out, like the coat behind the door, the phone next to the bed in the middle of the night and the goddam desk chair that was always in front of my left big toe when I got up without turning on the light.

The "Son-of-a-Bitching-Chair" was Alive, I knew for certain. Yes it was.  There was no doubt about it.  The chair had a secret life.  It was an agent provocateur.  It had a Chair Control Agent, telling it when to move, how close to creep to the bed, instructing it on how to rotate its five legs around so my left big toe was in the greatest danger of hitting at least one, if not two, of the destructively sharp casters jutting out from the legs, ready to slice my foot if it came within destructively sharp striking distance.

"Hah!  The light is on!  You missed me, Bastard Chair!"  It didn't answer, but I heard it hiss ...

... that was the gusting wind outside, Nit Wit ...

... and I was positive it heard me as I swore and stumbled passed.  I cursed the Chair and wandered out, unquestioned, through the places where Security Guards require Visitors to show passes.  Bet you didn't know you could be drugged by sleeplessness?

"Be quiet!  It doesn't make sense to be drugged by the LACK of something-"

The strong Atlantic wind caused the hospital walls to creak and groan as they pushed against the huge east wall, six stories high and as long as a football field, bending to the unrelenting pressure for minutes on end.

Administration has been off-center for years, opposed to change, recalcitrant, I say!  If the gale keeps up I'll get my wish and they'll rename this place The Leaning Hospital of Our Father of Disinclination.

Administration never understood the feeling, the mood, of the structure.  They were only there during the "normal work week," which is akin to diving on a Caribbean coral reef in broad daylight.  Oh, yeah, you see a fish and turtle or a sting ray now and then.  But dive the reef at night and it's ALIVE with crawly creatures and monstrous monsters who see, but are unseen by ordinary fools.

"The night is the Last Frontier for real people.  Sure, sure, Space is a frontier, too, but not for wholehearted night owls.  Just for astronauts worth billions to the Air Force brass who trained them.  Night is when the critters come out and the monsters of the health care hallways roam the corridors, the beasties doing beastly things.  You have to fight them in the dark, no light to guide your way.  It's tough to spot them 'cause they're Just around the bend or in stairwell, underneath the landing, making plans."

I'm sure I heard one moan and grunt, behind you, there, he's primed to pounce and eat your brains for dinner.  (Figuratively, Man, figuratively, not for real !)

"Dammit, will you PLEASE, SHUT UP?!!"  (Sometimes the maneuver worked, you know, thinking in CAPITAL LETTERS; and sometimes it didn't.)

As I was saying, "... after 31 hours into this 60 hour shift, the hospital becomes more than a 'building,' because we have labeled it a 'hospital.'   The word is Magic.  Buildings are only buildings, but Hos-PIT-als are  More, they Help, they Cure, they Make You Feel Better.  Pure poppycock, of course.  They're just concrete and steel, filled with uncirculated, triple-used, moist air and wheezing sounds from closets or from empty patient bathrooms down the hall."

The majority of patients believe the poppycock, you know. They can't 'forget' pit is a hos-pit-al's middle name because they never knew this was a pit, The Colossally Expensive Health Care Coliseum, where the docs and nurses are the Christians who the bureaucraps throw to the lions in the middle of the night.

"A noise!?  Listen!  Where'd it come from?  I thought we were alone."

We are.   Let's go check on a room upstairs I think you ought to see.

"Wait!  A body, that's a body in the elevator by the CCU.  What the hell ... ! ... lying there on the floor?"

Gray hair?  "Yep."

Female?     "Yep."

Ancient?    "Yep."

Look at the bracelet on her wrist.  It's got to say Lucy-something from 4-South.  It was a Tuesday night.  Before they could get her to the Coronary Care Unit she had a cardiac arrest in the back hall elevator.

"Where the pregnant 7th grader delivered in a wheel chair?"

Yep.  Same elevator.  Same spot.

"The kid was so scared she couldn't stop straining with her contractions.  The doors opened, the little mother pushed and out popped what's-her-name, to the amazement of three bewildered Visitors who had been told to use the Lobby elevators, not the ones in back. "

A dead white lady Tuesday night and a brand new 7-1b, 6-ounce black baby girl Wednesday morning.  Too bad Lucy's soul had to queue up in the elevator all night waitin' for the kid to come along.

"I spent a year one night waiting for the same elevator. The delay is built into the passenger flow management computer."  Must 'a been terrible when Ammonia Joe mopped up old Lucy's mess then turned on the noisy fan to dry the elevator floor. 

Yep. That was 5-1-2.  The Torture Chamber where we beat them up if they don't behave.   A part of me recalls it well.

"Oww!  Goddam!"  The paging system battered my ear drums.

"Code Blue 512! Code Blue 512!"

I do believe the old grouch likes to scream the calls for Cardiac Arrest to protest the perceived injustice done to her.  Since the hospital changed to silent pagers three years ago (to keep the general noise level down to a dull roar) "calling a Code" is the only time she is allowed to use the overhead paging system.  That put a big muzzle on the self-styled, Audible Performance Artist with the underlying sociopathic personality.  She has never forgiven Administration.  Now she takes each opportunity to belt it out with volume that could cause cardiac arrests in patients who don't even have heart trouble.  'Red Alert! Red Alert!'  she bellows.

"What's next: the Russians are coming?"  No.  Shut up.  Red Alert!  It's just a fire alarm test.

"It makes me vehement, being at Ground Zero under the speaker, when her damn voice explodes above my head.  Vehement, hell!  What it really does is piss me off."

Well, if you wouldn't make a fool out of yourself jumping out of your skin and running before you know what direction you're supposed to go maybe you wouldn't be so embarrassed and angry, I mean vehement.

"So what?  I recovered my composure.  The blast was just the start.  Don't you remember?  She called the Code when I was on the second floor and the patient was up on five, which made it fairly painful.  Further to go, more steps to leap two at a time, more burning chest pain with each gasping breath.  Trying to win the race against the Grim Competitor can be strenuous!"

You poor dear.  If you're so goddam frail, why don't you quit and get a day job?

"Piss off.  I was civilized, sophisticated and urbane when I made it to the floor.  I just headed for the door that looked like an Astronomer's Black Hole, sucking in everything within black, hole-sucking distance."

Too bad you didn't get guzzled up yourself.

"I'm tryin' to tell you about Lazarus, you stupid shit.  You want to hear about how people come back from the dead or not?"

Not really.  Lookin' at you at 2:30 in the morning when you haven't slept is close enough for me.

"Well, tough.  I can't stop thinking about it anyway, so I'm gonna remember it for you, like it or not.  They were all there, see, nine members of The Team, converging on the same door from different directions.  The only thing stronger than the Irresistible Force sucking them in was the Immovable Object, the New Security Guard with an I.Q. equal to his shoe size, trying to keep people out.  He thought they were frightened family members.  We, of course, set him straight."

Of course you did.

"No.  We really did.  Remember John Brown?  Respiratory Therapist.  6-foot 4, 305 pounds, ponderous and powerful, with a sense of humor based on terrorizing society.  He never cracked a smile.  He pushed the portable defibrillator up behind this guy, turned it on and handed me the paddles while the charger wound up like a jet plane gettin' ready to take off.  I grabbed them from him and said 'What are we doing with these charged out here in the hall?' and John says to the new guard 'If you don't move your ass, the doc is going to zap you into next week, understand?'  The guard's unheavenly body moved away with enough force to escape from a real black hole ... and John was standin' there tryin' to decide if he was gettin' more excitement out of watch in' this guy hightail it or watch in' his own 300 pound gut bounce up and down as he chuckled.  It don't take much to entertain some folks."

So, Lazarus was lying there, expiring, in 5-12 while you guys joked his life away out in the hall?

"Yeah, sure he was.  Well, NO, not actively expiring!  Now, get this.  The guard wasn't the only new face in the crowd.  Earlier some Newbie female from Respiratory Therapy slipped by the guard and made it to the head of the bed, she had a mask on the patient's face and was squeezing the black rubber ventilation bag for all she was worth.  I mean pumping, pumping, pumping, to bring him back to life.  Scared to death she wasn't going to do it fast enough, I guess."

Good.  At least you jokers got him ventilated.

"He had an I.V. in and running.  That got pulled out by accident in a sec or two.  John Brown was giving CPR like one of those machines that compresses cars into squares of squashed steel four feet square; effective, but excessive.  I shouted at him, 'Leave two, whole ribs unbroken and I'll buy you coffee after this is over, John!'  He backed off a little."

"The New Girl with the bag and mask was still pumping oxygen into the withered, 76 year-old remnant of a man. I grunted and got her attention, then moved my hand up and down slowly like I was patting a baby on the fanny.  She slowed down, squeezing the bag in time with my hand motion.  I felt like Leonard Bernstein, no, Seiji Ozawa; no, Leonard Bernstein (I decided I couldn't be Ozawa because, at that moment, I couldn't spell his name correctly."

And we all know correctness is essential during a Code.

"Right.  So, the EKG monitor leads were on his chest, the monitor screen lit up, everybody stopped bagging and pumping and shouting and fell silent for the count of three, watching expectantly.  And what did they see?"

NOTHING.

"Right!  You remember now?  No cardiac squiggles on the screen, just a straight line on the monitor.  So, I shout 'GO!' Like releasing Stop-Action on a DVD, the crew goes into violent motion again.  Little paper boxes full of drugs almost tore themselves open, vials pulled themselves out of wrappers and needles shoved themselves onto I.V. tubing.  Big John kept pumping, ribs kept cracking, sweat started rolling off people who only 'glow' at any other time."

"STOP!"  I shouted.  The word is magic.  It's like I pressed the DVD Pause Button again, the Action stops.  Nothing again.  No monitor pattern.  No palpable pulse.  No pressure in the cuff. Then the looks began.  I checked the nurses.  The nurses checked each other. The Head Nurse nodded agreement.  The New Girl wanted to start again. I nodded "No" and everyone agreed.  No use.  The Code is "called" again, but this time "called" means "stopped."

The papers were signed, the switches turned off, the sighs of resignation filled the air.  The sheet was pulled over him and shattered nerves begin to mend themselves.  No one noticed, until the silence let us feel it.  Our bending backs and arching necks and pumping arms had worked for ninety minutes ... it had seemed like seconds.  We had worked so hard our lives stood still a while, and in the end his life stood still forever.

"We're crazy, huh, for thinking we could bring guys back like this.  Oh, well."

Go downstairs and go back to bed.

"I'm not through yet.  Don't you want to hear the end of the story?  I started to leave the floor.  The elevator door slid open, like the entrance to a mine shaft.  I wanted to crawl in and have it take me to a secret Call Room in a subterranean sanctuary, solitary and sleep-o-pedic.  But what to my wondering ears should occur, some idiot screaming ... "

"Wait!  He moved, My God, the patient moved!"

Yeah, sure he did.

"No.  Really, he did, look!"

"It ain't enough we've damn near killed ourselves work in' on this guy already, now here we go again.  It seemed so violent before, yet moved at twice the pace this time the Black Hole sucked us in.  We had pumped and bagged and prayed, and now we stood in disbelief.  The patient moved, he spoke, he looked around and made a feeble try to reach his chest where John had caused his sternum to nearly touch his spine more than once this evening."

"What happened?"  He spoke with difficulty.  "What'er y'all doin' heer?  Ah din't call no Nurse nor none of you."

"He coughed and winced.  He hurt.  The pain he felt was very real for those of us who caused it, too.  We held our breath collectively and then we exhaled.  Does he remember, is he aware we gave him up for lost, we stopped and he restarted on his own, does he know how it happened?  An LPN in the back giggled.  The New Girl cried. I laughed and didn't believe my eyes.  We have truly seen Our Lazarus return, just like the Good Book says.  It made us fantasize that other forces might assist hard science with its work throughout the universe."

In a sane world, it had been an insane night.  The whole episode came back in painful detail as I walked by the door.  Now, two years later, I still recall my speech to the New Girl From Respiratory Therapy:

"You're right, of course. You pump the bag real fast, you blow more oxygen INTO the patient's lungs. But each time he exhales he will blow off too much carbon dioxide, you know, C02. If he blows off all his C02, he won't have any left to stimulate his respirations.  He won't take a breath in or blow one out.  So it will look like he has died."  She vowed she wouldn't bag too fast again.

If I have told you twice, I've told you once too often ... "Oh, no.  You're not going to lecture me again, are  you?"  Yes.  I do repeatedly thanks to your short attention span: I only hit you verbally because you need it.  It always hurts you more than it does me   ...   uhh, sorry, it always hurts ME more than it does you ... whatever ...

The Lessons  …

            Don't forget to watch what everyone is doing all the time,

don't forget to make sure every  job is being done right; and,

don't forget that nothing's really over until  ...

"I know, I know.  'Nothing's really finished until the Overkill Official doing chest compressions has broken every rib so the Fat Lady couldn't sing if she wanted to.'  Now can we stop?  I think I am getting tired enough to go to sleep if I can find the Call Room."

If you want to.  Not that you'll be able to sleep, but you may have forgotten the Total Hole Count in the ceiling tile, so you can start counting all over again.  Bet you won't bag it until dawn.  Wanna lay five bucks on it?

"Plug it up, will you.  For your information I'm not a betting person.  Besides, I'm NOT stopping my medicine, I'm going to take MORE.  Maybe then I can get rid of you and enjoy some silence on the Night Frontier alone for once.  Now go away."

I pulled the bottle from my lab coat, took a pill and turned and felt alone.  I looked around and Lazarus was gone, 5-12 was empty.  But, I was not alone and never would be in THIS hospital.  I have company galore.  Patients long-gone, but their stories endure in every passageway, about the lives of patients permanently admitted to the rooms of the "mental" hospital in my mind.