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by Murder

  The symptoms of rising blood sugar and impending DKA are fatigue, shortness of breath, nausea, lethargy, somnolence, confusion, and finally coma and death. The person may become irrational, delusional, maybe combative and angry, and even have hallucinations. As you can see, the symptoms of diabetic ketoacidosis and hypoxia are very similar. Diabetics have been arrested for DUI because they were driving erratically and failed a field sobriety test, only to be found later to have diabetes.

  The combination of low oxygen and rising blood sugar is additive so that the symptoms and the danger level progress much faster. This is more pressure for your firefighters and a true ticking time bomb. They now have to get oxygen and insulin to him and have less time to do so.

  Perhaps they could open a hole and supply oxygen, but by then he could be too far gone from his diabetes to follow instructions or give himself insulin. The opening would be too small for anyone to get through to help him, and something might prevent them from making the hole bigger. A gas line? Electrical conduit? Steel beam? Wall cave-in?

  Cool stuff. Just when it seems to be over, it isn't.

  Can Paramedics Determine If an Accident Victim Is Alive by Measuring Liver Temperature?

  Q: I read somewhere that paramedics can use some type of apparatus to do a liver test and determine if an accident victim is alive or not. What is this test?

  A: Paramedics use vital signs (blood pressure, pulse, breathing, consciousness) to determine if someone is alive, dead, or in transi-

  tion. If these signs are absent, they begin cardiopulmonary resuscitation (CPR) and ask questions later.

  The liver test you refer to is done by the coroner or the criminalists under his direction to aid in the determination of time of death. The apparatus is a thermometer, and it is inserted into the liver to determine the core body temperature, which helps in the timing of physiologic death. It serves no other purpose as far as I know. It definitely has no place or value in the treatment or evaluation of an injured individual.

  I can't imagine any situation in which a paramedic would do this—that is, unless he wanted the victim's family to file assault charges against him. Until the victim is pronounced dead by an M.D., he is still alive, and therefore this would be an assault. If the victim lived, it would definitely be an assault.

  The duties of paramedics are to support, stabilize, and transport the ill and injured under the direction of the nurse at the base station with whom they have radio contact. The nurse, in turn, works under the direction of the M.D. in the ER where the base station is located. This M.D. would never allow anything like this to occur since it has no place in patient care but is, rather, a "coroner's tool."

  What Is the Difference Between a Psychologist and a Psychiatrist?

  Q: What are the differences, if any, between the training and abilities of psychiatrists and psychologists? Can they both do psychotherapy and prescribe drugs?

  A: Clinical psychologists may have a master's degree and a Ph.D. They do not possess M.D. degrees. They can advise, counsel, and provide various types of psychotherapy. They cannot prescribe drugs or oversee medical therapies.

  Psychiatrists are medical doctors. They attend medical school

  and then complete a residency and maybe a fellowship program in psychiatry. In addition to the services provided by clinical psychologists, psychiatrists can prescribe medications, admit and attend patients in the hospital, and perform all the medical interventions of their specialty.

  Both can be effective in helping patients with psychologic problems since this depends more often on compassion, understanding, and common sense than on level of training.

  MEDICATIONS AND DRUGS

  What Are the Effects of the So-Called Date Rape Drugs?

  Q: What are the major effects of the date rape drugs?

  Do they need to be drunk as soon as they are placed in a drink to be effective? For instance, could my villain place one of them in a bottle of water and then appear to freshly open it for someone to drink at a later time?

  How aware is the victim after being drugged? I know that there is amnesia afterward, but when you are under the influence, do you know what is happening?

  How much should be given to immobilize someone?

  Could my villain perform surgery on the victim in this state?

  A: The major date rape drugs are Rohypnol (flunitrazepam), Ecstasy (3,4-methylenedioxymethamphetamine), GHB (gamma-hydroxybutyrate), and Ketamine (ketamine hydrochloride).

  Ecstasy, GHB, and Ketamine are commonly found at raves—all-night dance parties that attract huge crowds of teens and young adults. The rave culture has its own music, dress, and drug use patterns. Some ravers claim these drugs seem to enhance the rave experience, especially if taken with alcohol.

  Rohypnol, GHB, and Ketamine are commonly used in "date" or

  "acquaintance" rapes. They are powerful and cause sedation, a degree of compliance, poor judgment, and amnesia for events that occur while under their influence. It is this that makes them effective in date rape situations. A small amount of GHB or Rohypnol can be slipped into the victim's drink in a bar or at a party. She may appear to be no different, but she may leave with her assailant because judgment is impaired and euphoria is enhanced. Only later will she realize that something happened, but her memory of events may be spotty or absent.

  With any of these drugs, users may act, talk, and appear normal to those around them. Or they might seem happy, excited, pleasantly sedated, or intoxicated. Or the victim may become "drunk" quickly, develop slurred speech, and, of course, must be put to bed. Or driven home. Or robbed. Or murdered. In any event, she doesn't put up much of a fight. The reaction varies from person to person.

  Let's look closer at these drugs:

  Rohypnol (street names are Roofies, Roaches, Rope, and Mexican Valium) is a benzodiazepine sedative in the same family as Valium, and it was developed to treat insomnia. Currently, the drug is neither manufactured nor approved for use in the United States, but it is available in Mexico and many other countries. It is manufactured as white 1- and 2-milligram tablets that can be crushed and dissolved in any liquid. The going rate on the street is about $5 a tablet. It takes effect twenty to thirty minutes after ingestion and peaks in about two hours; its effects may persist for eight to twelve hours.

  Roofies typically cause sedation, confusion, euphoria, loss of identity, dizziness, blurred vision, slowed psychomotor performance, and amnesia. The victim has poor judgment, a feeling of sedated euphoria, and poor, if any, memory of events. Victims may suddenly wake up or reenter reality hours later with spotty or no memory of what has happened. Rarely, Rohypnol can cause anger and aggressive behavior.

  Ecstasy (street names are E, X, XTC, MDMA, Love, and Adam) was originally patented in 1914 as an appetite suppressant, but it was never marketed. It is made in underground labs and distributed in pill or capsule form. It has amphetamine (speed-like) as well as hallucinogenic effects. The user has enhanced sensations and feelings of empathy, a mood lift, increased energy, and occasionally profound spiritual experiences or an equally profound and irrational fear reaction. It may cause increased blood pressure, teeth grinding (bruxia), sweating, nausea, anxiety, or panic attacks. Rare cases of death have been reported from malignant hyperthermia (sudden and marked elevation of body temperature to 106, 108, or above, which basically "fries" the brain).

  Now the confusing part. Both MDMA and GHB are sometimes referred to by the slang term Ecstasy, though they are actually very-different compounds. The street purchaser doesn't always know which one he is getting.

  GHB (street names are G, XTC, E, Liquid Ecstasy, Liquid E, Easy Lay, Goop, Scoop, and Georgia Homeboy) was developed over thirty years ago and was sold as a natural food supplement and muscle builder. It comes as a white powder that dissolves easily in water, alcohol, and other liquids. Currently, it is often found as Liquid E, a colorless, odorless liquid that is sold in small vials and bottles for $5 to $10.

  The effects of G
HB appear quickly, five to twenty minutes after ingestion, and typically last for two to three hours. It causes loss of inhibitions, euphoria, drowsiness, and, when combined with alcohol, marijuana, cocaine, and many other drugs, increases the effects of these drugs. Many kids use it to enhance the effect of alcohol for a "cheap drunk." Users report that GHB makes them feel happy, sensual, and talkative. They may experience giddiness, drowsiness, amnesia, an increased sense of well-being, enhanced sensuality, and sometimes hallucinations.

  Ketamine (street names are K, Special K, Kit-Kat, Purple, and Bump) is a rapid-acting intravenous or intramuscular—and therefore injectable—anesthetic agent that causes sedation and amnesia. It was a common surgical anesthetic agent in the 1970s but fell from favor partly because of its unpredictable hallucinogenic and psychiatric side effects. It is still occasionally used medically and is popular in veterinary medicine as an animal sedative. In fact, the Ketamine that appears on the street is often stolen from animal hospitals and clinics.

  A newcomer on the drug scene, it is also available as a white powder or in pill form. It is rapidly absorbed after ingestion or if snorted, which is the most common method of usage. Special K goes for $10 to $20 a dose. When snorted, it takes effect almost immediately and is fairly short in its duration of action—an hour or two.

  Many of its effects are similar to Ecstasy, but it also possesses dissociative effects, which means the person separates from reality in some fashion. Often the user experiences hallucinations, loss of time sense, and loss of self-identity. One common form is a "depersonalization syndrome" where the person is part of the activities while at the same time is off to the side or hovering overhead watching the activity, including his or her own actions. This reaction is common with PCP (Phencyclidine, Angel Dust), which was very popular in the 1970s and 80s.

  Users call these effects "going into a K hole." I would suspect a K hole is similar to Alice's rabbit hole, where time, space, and perceptions become distorted.

  And don't forget the original Mickey Finn or Mickey, a staple in 1940s and 50s detective novels and movies. It was made by combining alcohol with chloral hydrate syrup.

  Easy to come by, chloral hydrate is sold as a children's sedative under the name Noctec. A teaspoon assures a good night's sleep— for the child and the parents. However, when mixed with alcohol, it is a powerful sedative. It originally came as a liquid that was added to a mixed drink; now it comes as a soft gelatin capsule as well. Its smell and taste, which is minimal, is easily covered by the alcohol and the mixer of the cocktail.

  Since the introduction of barbiturates, chloral hydrate's use as an adult sedative has waned. "Barbies" are more effective and possess fewer side effects. Of course, barbiturates can be mixed with alcohol and lead to the same result. This combination is a common method of suicide.

  Now, let's get to your questions.

  These compounds are stable and could be added to water, juice, or alcohol hours or days ahead of time. They dissolve easily, and the victim usually has no indication that her drink has been altered.

  Even as the drug begins to take effect, the victim is not likely to know she has been drugged, but, rather, feels as if she has had one too many. She is probably happy and euphoric. She may laugh and giggle and be open to persuasion, or she may become very sleepy and lethargic.

  Dosing is a problem with GHB and Ecstasy since they are cooked up in garages and basements, but Rohypnol and Ketamine are pharmaceutically manufactured. A triple or quadruple dose of either would likely put the victim out. But a single or double dose might make her compliant, and she would willingly go wherever her assailant suggested. In the scenario you outlined, the victim might willingly participate in sex or other activities, but the pain of surgery would definitely awaken the victim. She may not be able to put up much of a fight or make a great deal of noise, but she wouldn't be very cooperative, either.

  Only Ketamine would be strong enough to serve as a surgical anesthetic, and even that would probably require the injectable variety. None of the others are likely to induce coma or complete sedation unless a large dose that could be fatal were administered.

  A more realistic scenario might be for the victim to be given a drink spiked with Rohypnol or GHB, enticed to a remote area, and subdued. Then injectable Ketamine could be used as an anesthetic for the surgery.

  How Do Drugs Alter the Size of the User's Pupils?

  Q: I've read that different drugs affect the size of the pupils in different ways. What are the effects of marijuana, speed, heroin, and some other common drugs on the pupils?

  A: The pupils are highly reactive (Figure 7). They rapidly respond to various external and internal stimuli. Enter a dark room, and they dilate (enlarge) to gather more light. Step into the sunlight, and they immediately constrict (narrow) to protect the delicate retina from light damage. Sometimes this reaction can be tricked. We've all heard the warnings regarding direct viewing of a solar eclipse. In this situation the blocking of the sun by the moon tricks the eye into thinking it is darker than it actually is. Light rays from the corona and from the edges of the sun just before and after the total eclipse are stronger than they appear. Staring at the eclipsed sun directly can result in retinal damage.

  In addition, through neurological and chemical connections, the pupils are intimately tied to the autonomic nervous system (ANS). The ANS is divided into two subsystems: the sympathetic (flight or fight) and the parasympathetic (feed or sleep). These two subsystems perform a constant balancing act. In an exciting or life-threatening situation the sympathetic side takes control. The heart rate and blood pressure rise, breathing increases, body temperature shoots up, and the pupils dilate. This is the result of a massive outpouring of adrenaline from the adrenal glands. The body is now prepared to fight or run. In a feeding or resting circumstance, the exact opposite occurs. Adrenaline levels are low, as are the heart rate, blood pressure, and body temperature, and the pupils tend to constrict.

  Certain chemicals may artificially produce similar reactions.

  "Downers" such as narcotics tend to relax and stupefy (no pun intended) and thus constrict the pupils. These include drugs such as heroin, morphine, and barbiturates. "Uppers," or speedlike compounds, are classified as sympathomimetic drugs since they mimic the effect of the sympathetic portion of the ANS. They tend to dilate the pupils. Cocaine, amphetamines, crystal methampheta-mine, Ecstasy, and many diet pills do this. Marijuana also tends to enlarge the pupils.

  How Safe Is It to Handle Cyanide?

  Q: What would happen if a person handling cyanide didn't wear gloves but had limited contact with it?

  A: Obviously, what happens is dependent on what exposure occurred, the concentration of the cyanide handled, and the point of exposure. But cyanide is a toxic and very dangerous substance.

  Cyanide can absorb directly through the skin and kill you. Gloves would prevent that. If the powder is shaken into the air and inhaled, it will enter the bloodstream rapidly via the lungs and kill you. If it is dissolved in a liquid and the liquid is spilled on the skin or splashed in the eyes, it will kill you.

  It takes only a small amount, and even if a doctor was standing right next to you, you would still die.

  Bad stuff. Unless you want your character to kill someone, then it's great. But there is no such thing as too much caution when handling it.

  Will Food Intake Prevent Alcohol Intoxication?

  Q: My character is in a situation where she must drink considerably while minimizing the effects of intoxication. Is there a substance that one can inject or ingest to combat alcohol intoxication (prior to consuming the alcohol)? What about the old adage that a significant quantity of bread will "absorb" the alcohol?

  A: Ingested alcohol is absorbed into the bloodstream very rapidly, and as soon as the blood passes through the liver, the liver begins to extract it from the blood and break it down. The level of alcohol in the blood at any given time is a dynamic balance between the rate of absorption from the ga
strointestinal (GI) tract and the rate of destruction and elimination by the liver.

  Bread does not absorb or soak up alcohol. But any food in the stomach, including bread, will slow the passage of alcohol into the bloodstream and thus lower the blood alcohol level. Alcohol is

  absorbed at all levels of the GI tract but enters the bloodstream faster from the small intestine, particularly the duodenum (the first part of the small intestine), than from the stomach. Fatty foods and milk tend to slow stomach emptying and thus would hold the alcohol in the stomach longer. The net effect is a slowing of alcohol absorption, so a cheeseburger and a milk shake might be a better pre-binge meal. Of course, drinking less and drinking slower makes the most sense for your character.

  How Dangerous Is It to Transport Heroin in a Swallowed Condom?

  Q: If you have a "mule" who has swallowed a condom full of heroin, how long before he passes it? How likely is the condom to succumb to digestive fluids and leak?

  A: Normal gastrointestinal (GI) transit time (the time required to go from one end to the other—you get the idea) is twenty-four to seventy-two hours, a broad range. The actual transit time varies greatly from one person to another and from day to day in a given individual. In addition to this personal variability, it changes with age, the type of foods eaten recently, any GI diseases that might be present, any medications taken, the level of hydration, and a ton of other factors. Transit time is hard to predict.

  That said, the mule would probably pass it in one to three days. Of course, the condoms are visible on an abdominal X ray, so if the customs officer or DEA agent suspects someone, he can easily find the contraband. He then gives laxatives to speed up the transit time and soon has the evidence in hand, so to speak.

  The carriers use condoms or other latex, rubberlike containers because the body can't digest them easily, if at all. However, the acids and digestive enzymes found in the GI tract, coupled with the peristaltic motions of the intestines, can weaken a condom and