Royal Pains

by D P Lyle

  Divya stepped forward, glaring at Jackie. “There is nothing more dangerous than someone who refuses to listen to reason. Dr. Lawson has explained the situation, yet you refuse to hear. You’re putting your daughter’s life at risk because you’re worried about appearances. I’ve seen this before. This neighborhood is full of it. If you love your daughter, if you really care about her, you will hear everything that Dr. Lawson has said and you will act on it.”

  Way to go, Divya. I wished I had said that.

  “And what are you?” Jackie said. “A physician assistant? Assistant? Not even to a real doctor. To one who left his practice in disgrace. One who killed a man.” She looked at me. “We know about you. We did our homework.”

  “Mrs. Crompton, I’m not here to defend myself,” I said. “Not that I really need defending. My only concern is that Nicole gets the help that she needs. You are actively interfering with that.” I turned toward Nicole. “You’re an adult. You’re over eighteen. You can make your own decisions and right now you need to make the right one.”

  Nicole started crying. “Why is all this happening to me? Why are you arguing about me? I’m fine. I’m getting married in a few days. I don’t have time for this.”

  Jackie exploded out of her chair and rushed to Nicole, pulling the crying girl to her. Her eyes flashed when she looked at me. “Get out. Get out now.”

  I knew I had gone too far. Pushed too hard. It was time to leave. I nodded to Divya and Evan. As I started toward the door, I stopped and looked at Nicole. Something was odd.

  Her facial expression was blank, her gaze locked on something in the distance, unfocused. Her chin rose slightly and her eyes rolled upward, revealing only the whites.

  Then it started.

  A full-blown seizure.

  Nicole’s body jerked. Jackie recoiled in horror. Nicole fell, but I stepped forward and caught her, easing her to the floor. Her body began jerking in the rhythmic tonic-clonic motions of a grand mal seizure. Her bladder emptied, staining the front of her dress.

  “Oh my God,” Jackie screamed.

  Mark rushed to her side and looked down at his daughter. “What the hell is going on?”

  “She’s having a seizure.”

  Divya grabbed her medical bag, which she had left near the front door. She handed me an oral airway. I slid it into place. Divya drew up five milligrams of diazepam and gave me the syringe.

  “What’s that?” Jackie asked.

  “A drug to help stop the seizure,” I said.

  “Should we get her to a hospital first?”

  “Not until we get this seizure under control. She could die from asphyxia or she could aspirate anything that’s in her stomach. We have to stop this now.”

  “How do I know what you’re doing is correct?” Jackie said.

  Divya glared at her. “Dr. Lawson has handled many seizures in his career. Just relax and let us take care of this.”

  I pushed Nicole’s dress up, exposing her left thigh. I jabbed the needle into the lateral portion of her quadriceps and injected the drug.

  We then started an IV and begin running fluids wide open. The seizure activity continued, so Divya drew up two hundred milligrams of phenobarbital. I gave it as a slow injection over two minutes through the IV line. It seemed like an eternity, but by the time I finished, the seizure had broken.

  Nicole began to moan, her head rolling from side to side, her arms and legs moving without purpose. She was in the postictal state: that time after a seizure when the brain works to reestablish its interconnections. A seizure disrupts normal brain transmissions and it takes several minutes to sort this out.

  I removed the oral airway, its job done.

  “What’s wrong with her?” Jackie said.

  “She’s in what we call the postictal state. It’s the confusion and disorientation that follows the seizure. She’ll be fine in a minute.”

  Sam walked into the room. “Dr. Lawson, I called the paramedics. They should be here momentarily.”

  Nicole’s eyes fluttered and finally she began to focus on the people around her, her confusion obvious.

  “What happened?” she asked. Her voice was weak and slightly slurred.

  “You’re okay,” I said. “You had a seizure. It’s over now.” She attempted to sit up, but I pushed her back flat on the carpet.

  “Just lie here for a minute. The paramedics are coming and will get you over to the hospital.”

  “The hospital? Why do I have to go to the hospital?”

  “To find out why this happened and make sure it doesn’t happen again.”

  Chapter 41

  While mother Jackie and father Mark seemed more upset that their perfect day had been interrupted than they seemed concerned, Nicole was scared. A more appropriate reaction under the circumstances. Seizures in adults are always serious business. Children often have benign seizures, usually associated with high fevers from ear infections or some other febrile process, but in adults they virtually always mean something more sinister.

  Earlier, while the paramedics loaded Nicole into their van, I told them I would ride in the back and keep an eye on her. They readily agreed. Jackie argued that if anyone rode with her daughter, it should be her, but when I asked her exactly what she would do if Nicole had another seizure, she took a step back and reconsidered.

  The ride to the hospital gave me a chance to ask Nicole about her medical history. Something she had refused until now. Turns out there was little to tell. She’d been healthy and athletic her entire life. No real family health problems either. She had done a brief stint in drug rehab, but she said she didn’t really need it, just went to pacify her mother. Five years earlier, she had been tossed from the saddle by a rambunctious horse and apparently struck her head, losing consciousness for a couple of minutes. This little bit of history was important because one of the causes of adult seizures is a scar from previous head trauma. An MRI would easily answer that question.

  Now Jackie and Mark were out in the radiology department waiting room, both chatting on cell phones, while I stood in the control room of the MRI lab. Nicole lay on the exam table beyond the shielded wall and window, eyes wide, lips trembling, and a death grip on the edge of the scanner table. The headphones that would pipe in music during the procedure were clamped on her head.

  The technician started to press the button that would slide Nicole into the doughnut of the MRI machine. I reached out and touched his arm.

  “Hold on just a sec,” I said. “Let me have a minute with her.”

  I pushed through the door that connected the control room to the MRI lab. I lifted the headphones away. “You okay?” I asked.

  “Scared to death. What if I have some terrible brain disease? Or a tumor? What if I can’t get married?”

  “Take a deep breath and relax. Don’t let your imagination run wild.”

  “Hard not to. After what happened. I mean, I wet my pants. What’s that all about?”

  I smiled and took her hand. “That’s not uncommon with seizures.”

  She sighed. “It’s embarrassing.”

  “Maybe. But I don’t think that’s what anyone will remember about what happened today.”

  “Is this going to hurt?”

  “No. It’ll be a little noisy, but you won’t feel anything.”

  She nodded.

  “I’ll be right over there in the control room. Watching everything that happens.”

  “Can’t you stay in here with me?”

  “This is a single-passenger vehicle.”

  She laughed. “I’m sorry for being such a ninny. I’m not usually this way.”

  “Probably not since the last time you wet your pants,” I said.

  She laughed again. “You’re funny. Anybody ever tell you that?”

  “As the great Samuel Johnson once said, a physician’s job is to amuse the patient while nature makes her well.”

  Her face relaxed, as did her grip on the table’s edge. “Let’s get this
over with.”

  I reseated the headphones and left the room. The technician went about his job and forty minutes later the MRI was complete. It would take a half hour for the radiologist to review all the images, so I went out to the waiting room and told Jackie and Mark that the test was complete and that Nicole was doing well. The tech and I then wheeled Nicole back to the emergency department. Her parents followed.

  I then walked back to the radiology department and found Dr. Glenn Alford, the chief of radiology, studying the images. He turned and looked at me over half-glasses as I entered. Behind him the images of Nicole’s MRI were displayed on tandem computer screens.

  “Hank,” he said. “Is this your patient?”

  “I’m not sure.”

  He raised an eyebrow.

  “Let’s just say her parents and I don’t see eye to eye.” I nodded toward the images. “See anything?”

  “Not yet but I’m just getting started. Pull up a stool.”

  MRI images have always fascinated me. They are a look inside the body like nothing else can provide. They show things that even a surgeon would never see. The clarity of the images exposes even the tiniest defects in organs such as the brain.

  I spent the next twenty minutes going over each image with Glenn until he finally removed his glasses and placed them on the table beside him.

  “This is about as healthy as a brain can be,” he said. “At least structurally. I don’t see anything. Definitely no tumors, scars, or evidence of infection.”

  “That helps a lot. Thanks.”

  “I’ll dictate the formal report and it should be on her chart shortly.”

  By the time I returned to the emergency room, neurologist Dr. Martin Gresham was examining Nicole. Mark and Jackie stood against one wall and looked up as I came in.

  “The MRI is normal,” I said.

  Dr. Gresham nodded. “As is her neurologic examination.”

  “What does that mean?” Jackie asked.

  Gresham turned toward them. “It means that she doesn’t have a tumor or infection or anything like that. Which means she could have some form of epilepsy or it could be some chemical abnormality.”

  Jill stepped into the room. She handed me a lab report. “All the labs aren’t back yet, but this is all we have so far.”

  I scanned the results. They weren’t surprising: low potassium and magnesium, elevated thyroid, and a digoxin level of 2.1. Not as high as in the others, but high enough. The drug screen hadn’t yet been completed, but I knew it would show amphetamines.

  I handed the sheet to Gresham and he, too, studied it. I saw his jaw tighten and his brow furrow. He gave me a quizzical look. “This doesn’t make any sense.”

  “Actually it does,” I said.

  “What is it?” Nicole asked.

  I walked over to her. “It’s exactly what we saw in the other patients I told you about.” I glanced up at Jackie and Mark. “Those pills you’ve been taking cranked up your thyroid, messed up your electrolytes, and did all the nasty things that I saw in that other young lady.” I looked back down at Nicole. “You’re very lucky.”

  Gresham looked at me. “Want to tell me what’s going on?”

  I did.

  Gresham didn’t hide his shock well. “You’re telling me that this Morelli guy is handing out pills that contain all this?”

  “Exactly. Julian Morelli is quite a salesman. Not much of a nutritionist but one hell of a salesman.”

  “Code blue. Rolling in the front door right now,” I heard nurse Susan Foster say as she rushed by.

  Chapter 42

  I rushed from the cubicle as the paramedics blew through the front double doors and into the nearest of the two major treatment rooms. I caught a glimpse of a woman with dark hair.

  Jill and I both hurried down the hall and into the treatment area. The woman was Amanda Brody. She was awake and moving her extremities but appeared to be disoriented and confused, eyes glazed. She didn’t seem to recognize me.

  “What happened?” I asked one of the medics.

  “Collapsed at home,” he said. “We found her unresponsive and in V-tach. She converted with a single shock. We gave her a hundred of lido. She was stable on the way over but just now jumped back into V-tach. BP is seventy palpable.”

  I looked at the portable monitor and saw that she was indeed in V-tach. Rate around 180.

  “Let’s shock her,” I said.

  Nurse Susan Foster began switching the EKG lead wires over to the wall monitor while another nurse pressed defibrillator monitor pads into place.

  I shook Amanda’s shoulder. “Amanda? Can you hear me?”

  She didn’t respond. Her blood pressure was too low to supply blood and oxygen to her brain.

  “Three hundred watts?” Susan asked.

  “That’ll work,” I said.

  She spun the defibrillator dial to three hundred and pressed the charge button. The unit emitted a soft whine as it transferred current into its capacitor. She smeared electrode gel on the two paddles and rubbed them together. She glanced up at me as if to ask if I wanted to do the honors. I nodded for her to go ahead. She pressed the paddles to Amanda’s chest.

  “Clear,” she said.

  She discharged the defibrillator. The audible thump of the discharge was followed by a slight jerk and arcing of Amanda’s body. She let out an audible moan. The monitor showed she was back in a normal and steady rhythm.

  “Amanda?”

  She looked up at me. “Hank? What happened?” Her wide-eyed gaze shifted right and left. “Where am I?”

  “In the ER. Your heart was acting up. Right now it looks like we got it back to normal.”

  “What’s going on here?”

  I turned to see Andrew Weinberg, the ER doc.

  “This is Amanda Brody,” I said. “Episode of V-tach at home and another just now.”

  “And another.” Weinberg nodded toward the monitor.

  I turned. Amanda was back in V-tach.

  Weinberg moved forward. She was his patient now, so I backed away and stood near the foot of the bed.

  Over the next thirty minutes, Amanda received three more electrical shocks, two doses of lidocaine, intravenous potassium and magnesium, a chest X-ray, an EKG, and a boatload of lab work. Finally, her rhythm stabilized.

  Susan Foster showed up with some of the lab work. “There’s an epidemic of this stuff today. Her potassium and magnesium are low, thyroid levels over-the-top, and look at this.” She handed me a lab slip.

  Amanda’s digoxin level was 6.4. Deadly high. Explained the arrhythmia. I handed the results to Weinberg. He read over them.

  “This is like that other girl,” he said. “Nicole Crompton.”

  “Both were taking the same weight-loss pills,” I said.

  “Which means she’ll have amphetamines in the mix.”

  “I’d be surprised if she didn’t.”

  “What do you think about giving her Fab fragments?” Weinberg asked.

  “With a level that high, I think that’s the right choice.”

  Besides all the nasty things that excess digitalis can do, things like nausea and vomiting and deadly cardiac arrhythmias, it’s a bitch to get rid of. The body dumps it through the kidneys, but that takes days and Amanda would be in jeopardy as long as her digitalis level remained high. Fab fragments are digoxin-specific antibodies that immediately bind to and inactivate the drug.

  By the time the Fab fragments were given, the drug screen returned. Amphetamines, type not yet known. That would take further testing. I already knew what those results would show. She would have the same ephedrine-like chemical that was found in the pills Julian had dispensed

  While I was going over everything we had uncovered with Amanda and explaining to her just how lucky she was, Jill stuck her head in the cubicle.

  “Her husband’s here. Should I bring him back?”

  I nodded.

  She returned a minute later with Amanda’s husband, Daniel. He rushed
to her side.

  “What happened?”

  “You better ask Hank,” Amanda said. “I don’t remember much.”

  I walked him through everything that had happened and the results of Amanda’s blood tests.

  Daniel took it all in soberly, but I knew inside he was seething. Daniel had a temper. Daniel would not sit quietly and let something like this pass. Daniel was connected politically and had a portfolio thick enough to buy the hospital. Maybe three or four hospitals.

  He kissed Amanda on the cheek. “I need to talk with Hank for a minute.”

  “Are you going to talk about me?”

  “No. Julian Morelli.”

  Daniel, Jill, and I walked outside the cubicle. Daniel looked up and down the hallway. The emergency room was busy, nurses moving quickly from one treatment room to another, a lab tech carrying a basket of blood samples down the hall, a woman shouldering a red-faced, crying baby, patting its back, doing her best to comfort the infant, her own anxiety etched on her face.

  “Is there somewhere we can talk?”

  “My office,” Jill said.

  Once there, Jill sat behind her desk, I took a chair, and Daniel settled on the sofa along the left-hand wall.

  “I just want to make sure I understand all of this correctly,” Daniel said. “The pills my wife has been taking—the ones she got from Julian Morelli—might contain all these dangerous chemicals? Is that correct?”

  I nodded.

  “And there is absolutely no medical reason that she should be taking any of them?”

  “Each of the drugs in those pills have medical uses,” I said. “Except maybe the amphetamines. But Amanda didn’t need any of them. The digitalis leaf? That’s an old preparation that hasn’t been used in this country for many decades. It is literally crushed-up leaves of the foxglove plant, which means it’s impossible to accurately control the dose.”

  Daniel sighed and his jaw set. “This combination almost killed her?”

  “About as close as you can get,” I said. “She’s lucky that your housekeeper saw her collapse. Had she been in the bathroom or alone in her bedroom or somewhere where no one would’ve seen her, she very easily could’ve died.”