A 45 year-old man was brought to our hospital via ambulance after being found unresponsive at home. He works as a non-clinical staff member at the hospital and is known and loved by all. En route, he is somnolent, breathing about four times a minute, and has a normal blood sugar.
By the time he arrives in ER, he is on 15L oxygen via a non-rebreather mask. His peripheral O2 saturations are 70% on room air, 94% on the 15L. His core temperature is 88 degrees Farenheit. He is given a dose of Narcan and wakes up briefly, although he immediately dozes off again. His respiratory rate increases from four to ten times per minute and he appears to be guarding his airway. His urine tox is positive for cannabis (almost universal in this county) and methadone. He can't give any history and none of his distraught family can provide me with an accurate medicine list.
I admit him to ICU. Within a few hours, the Narcan has worn off and he desats into the 70s. I start him on a Narcan drip. A request to his PMD returns a medication list which includes Duragesic and Norco for pain, but no evidence that methadone has ever been prescribed for him. Again, when I ask his family if he took methadone given to him by friends or bought it off the streets, I get no useful information.
Days go by. I get the patient off the Narcan drip, hold all sedatives, begin feeding him as his wakefulness improves. However, it becomes evident that he has anterograde amnesia. He can't remember how many days he's been hospitalized, why he's there, and why I'm not letting him have anything beyond toradol for pain--even though the nurses and I repeat these nuggets of information constantly. He recognizes family and friends, remembers his job at the hospital, but is completely unable to tell me the events that led up to loss of consciousness.
On hospital day #4, a nurse is tidying up his bed sheets and finds a tablet among the folds. She shows it to me, and we puzzle over its significance. We show it to the hospital pharmacist, who runs it though a database and tells us it is methadone.
Now, it should be apparent to all that I am not giving this patient any methadone. Ten minutes of shuffling logbooks verifies that no one in the ICU has received any methadone, and that methadone has not been stocked in the ICU for a couple of weeks. (It isn't commonly used for ICU patients, anyway.) Therefore this tablet of methadone was brought in by one of the patient's friends or family members.
I huddle with the patient's family. I impose a strict limit on who may and may not visit him (close family only). Everyone who visits must leave their purse/empty their pockets on a table at the foot of the ICU bay. The curtain around his bed is to remain open at all times when visitors are present. No outside food is to brought to him. I repeat a urine tox, which is negative for methadone. Phew.
On hospital day #6, I'm really worried that this patient is still in a mental fog despite what seems like an adequate amount of time for the methadone overdose to wear off. I'm worried about hypoxic brain injury. I get another head CT--normal. On day #7, I get a brain MRI, which shows a couple of small lacunar infarcts, which look new. These don't, however, explain everything that's going on with him. On a whim--merely a whim!--I order another urine tox.
It's positive for methadone.
Pissed-off hardly described the state I was in. Spittin' mad might be a more accurate description. In a moment of horror, I realize that staff members have been coming in to visit him the entire time he's been there, despite my efforts to restrict his visitors. All hospital staff now the numeric keypad code to enter the ICU. Is it possible one of them--perhaps in an act of compassion, when he complained of pain--gave him methadone? I can't even wrap my mind around the concept.
I impose a flurry of new rules. No visitors unless they are chaparoned by trusted clinical staff member. No more staff members just dropping by--everyone gets a shadow. I toyed with the idea of changing the code on the ICU door, but the plant ops guy who recodes the door is a friend of the patient--where's the privacy in that?
Perhaps it is just as well that this was my last day on the service for a while. I sign-out to my colleague, and we agree that Adult Protective Services need to be involved. We also throw around the idea of transferring him to the other hospital in our community, where he is not as well known to the staff.
I don't know if they ever found out who the culprit was. The main question that nags at me: is it possible that prescription drug diversion is so acceptable that it would take place in the hospital, in a patient who is suffering from overdose, and possibly involve a hospital-affiliated worker? The mind boggles.
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