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thethinker42
11-25-2013, 08:36 AM
Picking the brains of the medically educated in between researching this on my own.

So here’s the basic scenario: I have a character who’s going to commit suicide by deliberately overdosing. He’s a regular coke and meth addict who’s messed around with various recreational drugs over the years, and has OD’d a few times before, but this time he means it. I’m undecided if he’s going to OD on his usual drug(s) of choice, or if he’s going to down some painkillers, so I’m totally open to info relating to either.

Ideally, I want him to OD fairly quickly and either be dead before the paramedics get there, or die shortly thereafter. (Authors are sick people.) The person who finds him does so within minutes of him taking the drugs, but dude needs to die.

What I need to figure out is how quickly he could start showing signs of an overdose, what those signs would be—and ideally if there are any signs that might tip off someone who has been around users before and might realize the person is overdosing before things get really bad. Also what the 911 dispatcher might tell the person who finds him. Hold his head at an angle to keep his airway open? CPR? …? (Only one person will find him, and it’ll take a few minutes before any additional help arrives)

Also, every article on the internet explains how to handle a scenario, first aid, treatments, etc., but they’re pretty textbook and assume things like the first responder keeping a cool head. I want ALL the variables. Things you’ve seen in overdose situations that an article might not mention or someone might not think of. Weird, out of the ordinary, ridiculous… anything. Drugs interacting in ways I might not imagine, patients who seemed like they would pull through but died anyway (and vice versa), anything.

I know this is all kind of vague, but the scene is still a bit nebulous. I want to make sure it plays out as realistically as possible, so seriously… anything you can add is incredibly helpful.
Thanks!!

asroc
11-26-2013, 12:43 AM
Well, how an OD manifests depends on many things: how much he takes, how he takes it, how tolerant he is to the drug, what his general health is like, what else he might have taken etc. A sufficiently large cocaine overdose can be fatal within a couple of minutes. Signs and symptoms can be pretty diffuse, though.

What's fairly common in the beginning stages is fast breathing, rapid pulse (but sometimes the pulse is slow instead), agitation and emotional instability often with aggressive/violent behavior, tremors, headaches, chest pain and nausea. That progresses to seizures, loss of muscle control (including bladder), irregular/interrupted respiration, cardiac arrhythmia, and finally on to coma and cardiac/respiratory arrest. It's not a pretty death.

If you want the guy to die, have him die before EMS gets there. Most ODs that get medical help in time survive. That applies to heroin, too, but if you do manage to kill yourself like that around here, it's generally at least partly due to heroin/other opioids (or you take some MDMA variation and die of dehydration.) I don't see fatal cocaine overdoses all that often. But for extra death, you can always combine cocaine and heroin and make a speedball.

What the dispatcher should tell the other guy depends in what the patient is doing at the time. If he's still breathing he should be put in the recovery position, which is a stabilized way to lay someone on their side in such a way that their airway is kept open. If he's not breathing, then yes, CPR.
Here's where many bystanders balk. These patients often have various bodily fluids on them by now, they might have been convulsing and the bystanders don't really want to touch such a patient. So it's quite possible to OD surrounded by your "friends" and nobody does anything. Then there are the people that base their "first aid" on something they vaguely remember reading or watching somewhere, like this one guy who tried to help his girlfriend by ramming a syringe into her chest based on what he'd seen in Pulp Fiction. He didn't have epinephrine available (fortunately), so he used a mixture of water and vodka. (Luckily he hit the sternum and the needle broke off. She wasn't as bad as he thought and ended up being fine. Don't know if they're still together.)

thethinker42
11-26-2013, 01:31 AM
Awesome, thank you! That's all quite helpful.

King Neptune
11-26-2013, 01:38 AM
You will have to decide on his drug of choice, because OD'ing on junk is different from OD'ing on Meth; although cardiac arrest is often the cause of death in both. Junkies fairly often drown on their vomit. And sometimes a junkie's heart can be restarted with an injection of saline directly to the heart.

thethinker42
11-26-2013, 06:08 AM
You will have to decide on his drug of choice, because OD'ing on junk is different from OD'ing on Meth; although cardiac arrest is often the cause of death in both. Junkies fairly often drown on their vomit. And sometimes a junkie's heart can be restarted with an injection of saline directly to the heart.

Of course. I'm just getting all the information about different types of overdoses, and then I'll settle on his drug of choice. :)

CoolBlue
11-26-2013, 07:29 AM
Hi TT42

You say you want to know ALL the variables. Well, good luck there, as has been alluded previously.

That being said, here are a few thoughts you may find useful:

1. Does the person really want to die?

There is a difference between a "cry for help" and someone who is determined to die. We see and treat many in the former category (some of them die, too). The coroner sees more from the latter category.

So, you say the person really wants to die. That means that they will not be committing this act in a way that would have them found until they are dead. You will need to take this into account if they are discovered nonetheless.

2. Overdose can mean many things. Dying from a overdose from most street drugs is rather uncommon if the person is found early.

They can do things to make death more likely.

Take an overdose while sitting on a high-up balcony perhaps. The fall will kill them when they tumble down.

You ask for unusual one: A wife of an anaesthetist wishes to kill herself. She manages to get her hands on a vial of Ketamine, gives herself a big intramuscular injection, and jumps in the swimming pool. (Real case)

3. Take a drug that kills rapidly. This means a lethal dose of cyanide, that sort of thing. A large dose of IV potassium. It burns like fire if a large dose and concentration goes in rapidly. Not something a druggie is likely to manage.

4. Multiple drugs. Here, there are many variables. We can usually figure out after a few hours what drugs have been ingested, but if they are not detected, and get into the system, you may die anyway.

The point here is, you die later. Often much later. If EMS gets to you, you may get charcoal, which will limit absorption of many drugs. In the ER you may get gastric lavage, particularly if you are unconscious, and have taken "extended release" medication.

Some of the most toxic drugs out there are drugs that work on the cardiac system. Beta-blockers and calcium channel blockers are bad in overdose. Despite our best efforts, we do on occasion get into a situation where nothing will save them. But understand that this is often much later, after decontamination, many drugs, cardiac pacing, and dialysis.

I hope this is useful, select and discard.

But the bottom line is: Folks are unlikely to die from regular street drugs if found soon after ingestion. Something else will need to happen as well. If it must be drug-related - a poly substance ingestion with cardiac drugs in the mix might do it. But later.

Have, er, fun!
CB

thethinker42
11-26-2013, 08:31 PM
Obviously there's no way to get ALL the variables, but I want as many as I can get. :) And thank you all -- this has been very helpful!

asroc
11-26-2013, 11:54 PM
And sometimes a junkie's heart can be restarted with an injection of saline directly to the heart.

Where did you hear that?

MagicWriter
11-27-2013, 02:47 AM
To the OP, - two things to keep in mind. Different drugs work on different receptors in the body. If your character overdoses on cocaine (stimulant), you can't reverse the reaction with heroin (downer), etc. You need to google if there is a competing drug, and find out what "it" or "they" are, for the drug that you chose. Drug of choice to compete against morphine (which is metabolized from heroin), is naloxone.

Also, if an ambulance shows up to help a drug overdose, keep in mind that ambulances are equipped for emergencies. Many of the drugs aboard have a higher dosage or a higher concentration over what you'd find issued for a patient that is recovering in a hospital.

I admire your wanting to research and find out all the facts. Just be careful not to get too caught up in the science of all this, most readers will get bored with the facts. Keep your scene as a story, don't let it become a science project.

thethinker42
11-27-2013, 03:11 AM
I admire your wanting to research and find out all the facts. Just be careful not to get too caught up in the science of all this, most readers will get bored with the facts. Keep your scene as a story, don't let it become a science project.

No worries there. I'm just making sure I have the background straight so the few details I include will sound authentic. :)

King Neptune
11-27-2013, 03:33 AM
Where did you hear that?

That's what junkies do.

Cath
11-27-2013, 03:53 AM
Reminder: treat any medical advice recited on the internet with skepticism unless confirmed by a medical practitioner that you know and trust.

Cath
11-27-2013, 03:58 AM
That's what junkies do.

Do you have a source for that?

CoolBlue
11-27-2013, 07:13 AM
Do you have a source for that?

Quentin Tarantino, in his video of the technique demonstrated by Dr. Johnny Revolting in Pulp Fiction! :) :) :)

KN may be referring to Epinephrine (Adrenaline) solution in saline being injected into the heart. That went the way of the dodo bird a long time ago.

CB

King Neptune
11-27-2013, 04:52 PM
Do you have a source for that?

I do not give the names or other identifying information of criminals. They generally like to avoid having such information made public. If you want more about then I suggest that you search on google. Using "heroin overdose saline solution" I got this http://forum.opiophile.org/archive/index.php/t-2791.html and many other results, and some of those results say that it is ineffective.

asroc
11-27-2013, 08:11 PM
Well, several posters in your own source correctly point out this is bullshit. I can imagine that there are people who try this, but it doesn't work and it's a terrible idea.
Drug addicts are not a reliable source for medical treatment. I treat drug overdoses for a living. Saline injection does not restart a stopped heart, ever.
If you find someone who has overdosed or is otherwise unconscious a) call 911, b) if they are breathing, put them into the recovery position and make sure they keep breathing, c) if they are not breathing, clear their airway and start CPR. No slapping, no stun gun, no "antidotes," no injection with anything, especially not into the heart. At best you'd only be wasting time with that, but those are great ways to kill people, too.

BrightSera
11-27-2013, 08:17 PM
I agree with everything Asroc said, except if they're not breathing, check for a pulse first. If there isn't one, then start CPR. If they have a pulse, do rescue breaths. No sense breaking anyone's ribs for fun if you can avoid it. ;)

CoolBlue
11-27-2013, 09:12 PM
Just in case anyone is interested in where this idea comes from (this being a research thread for writing, not a scientific debate, after all):

Intracardiac injection of epinephrine became popular about a century ago.

Here is the link to the first page (http://jama.jamanetwork.com/article.aspx?articleid=235030) of the article. The date is 1923.

Over time, the practice fell into disuse. Nevertheless, it was still being used on occasion. Here are the ACLS guidelines from 2000 (http://circ.ahajournals.org/content/102/suppl_1/I-129.full), where the cautious use of intracardiac epinephrine is mentioned as a last resort.

The use of intracardiac epinephrine was initiated by cardiac surgeons during thoracotomy, in other words, when the chest was open, the pericardium (sac around the heart) was open, and the injection could be done under direct vision, thus limiting damage to structures.

More recently, the idea of doing thoracotomies in the ER, for resuscitation has had a bit of a resurgence. Here is an article from 2013 (http://www.omicsonline.org/intracardiac-epinephrine-injection-during-open-thoracotomy-and-circulatory-arrest-2155-6148.1000341.pdf) describing the use of epinephrine for direct injection into the heart.

There are other reasons for putting a needle into the chest. One of them, is to attempt to drain fluid that has collected in the pericardium, the sac that surrounds the heart, in an attempt to relieve pressure on the heart.

Often, we will put saline into the syringe, so that it is easier to identify air coming back through the needle, meaning we are in the lung, not the pericardial sac, or heart.

This is all rather desperate stuff, and certainly not the kind of thing to do in the field, Vincent Vega notwithstanding.

So, there are some things to play with here, if you wish to write fiction that skirts the borders of realism.

However, injecting saline into the heart to resuscitate a heroin overdose will likely not work to satisfy most critics.

Now, have an off-duty ER doc who just happens to have a vial of epi in his bag, with a syringe and suitably long needle, gonads of titanium, and really good malpractice insurance - well, go for it! ;)

In the real world, not so likely. But this is FICTION, not FRICTION. It''s OK to be a little wild in our imaginings.

CB

thethinker42
11-27-2013, 09:24 PM
In the real world, not so likely. But this is FICTION, not FRICTION. It''s OK to be a little wild in our imaginings.


I suspect you've never received a lengthy e-mail from a reader detailing your every factual failure in a book. :D Or even more fun: a review doing the same.

ETA: Obviously it's okay to stretch the truth in fiction here and there, I'm just trying to be as close to reality as possible. Otherwise I'm afraid it'll jar readers out of the scene. The overdose scene is relatively short and not detailed down to the letter, but I don't want to mention convulsions only to find out the drug of choice wouldn't cause them, or have the guy die quickly when it would actually take him a while.

CoolBlue
11-27-2013, 09:36 PM
I suspect you've never received a lengthy e-mail from a reader detailing your every factual failure in a book. :D Or even more fun: a review doing the same.

:)

No, I haven't. For that I would need to be published. ;) Something I am working on.

Of course, it would mean someone read my book!!!

My point was that there was a wisp of truth to the rumour, that could be used, if carefully dissected. Your mileage, as the saying goes, may vary.

And... a book REVIEW. Wow. We've obviously experienced different thrills in life, so far. Your writing thrills make me envious. Don't envy my medical thrills, sometimes the reviews can be a bit too detailed, and harsh too. :)

Best
CB

thethinker42
11-27-2013, 09:41 PM
:)

No, I haven't. For that I would need to be published. ;) Something I am working on.

Of course, it would mean someone read my book!!!

You'll get there! :)


My point was that there was a wisp of truth to the rumour, that could be used, if carefully dissected. Your mileage, as the saying goes, may vary.

Yep, I hear ya. This is why I'm collecting as much info as I can, from normal to not so normal, so I know what the possibilities are.

This poor character. I've been so mean to him. And the guy who finds and fails to save him. *cackles*


And... a book REVIEW. Wow. We've obviously experienced different thrills in life, so far. Your writing thrills make me envious. Don't envy my medical thrills, sometimes the reviews can be a bit too detailed, and harsh too. :)

Reviews are terrifying! LOL I'm glad to have them -- they're great for sales -- but I avoid reading them as much as possible unless a friend looks at them first. I know, I'm a wimp. I admit it.

Cath
11-27-2013, 09:50 PM
In the real world, not so likely. But this is FICTION, not FRICTION. It''s OK to be a little wild in our imaginings

Yes of course it is, but if you want any old unsubstantiated information, use Google. The point of this forum is to get expert advice and real world experience, so it is absolutely fair to ask for sources here.

CoolBlue
11-27-2013, 09:56 PM
Yes of course it is, but if you want any old unsubstantiated information, use Google. The point of this forum is to get expert advice and real world experience, so it is absolutely fair to ask for sources here.

Oh, I was not suggesting that asking for sources was not useful, Cath. Not at all.

I was trying to add a bit of detail to the misguided idea that injecting saline in the field would be a useful idea. I was concerned that the baby might be found in the frozen bathwater that was tossed out the window, so to speak.

And, I did add references. :D

No offence intended. If any was construed, my apology. (Why is this emoticon thing not working? Runs off to change the batteries)

Best
CB

asroc
11-27-2013, 10:16 PM
I agree with everything Asroc said, except if they're not breathing, check for a pulse first. If there isn't one, then start CPR. If they have a pulse, do rescue breaths. No sense breaking anyone's ribs for fun if you can avoid it. ;)

Modern guidelines no longer trust laypeople to check for a pulse first. Ditto rescue breathing. I can't say I'm happy with hands-only CPR, but considering the average civilian's skill level there's certainly a reason it exists.

CoolBlue
11-27-2013, 10:23 PM
Modern guidelines no longer trust laypeople to check for a pulse first. Ditto rescue breathing. I can't say I'm happy with hands-only CPR, but considering the average civilian's skill level there's certainly a reason it exists.

:D
Yeah, pulse check AFTER the saline to the heart. :) :) :)

CB

BrightSera
11-27-2013, 10:30 PM
That's..concerning. I've been out of the field for years, unfortunately. I know about compression only CPR, but didn't realize they took it to bypass taking a pulse.

All those fictional half-dead people getting their chests squished around when all they need is the breath of life. But, at least, we know no ribs are broken since lay people are a bit squeamish about all the cracking and popping, right? ;)

CoolBlue
11-27-2013, 10:37 PM
All those fictional half-dead people getting their chests squished around when all they need is the breath of life.

OK, just to bring up a serious point.

What kills adults is the heart fibrillating, mostly after a heart attack. When that happens, there is enough oxygen in the lungs to keep them going for several minutes AS LONG AS BLOOD IS BEING PUMPED.

This is the most common presentation, say in a shopping mall.

What the person needs is to be defibrillated. Until that can happen, chest compressions are needed, not breathing.

Press Hard, Press Fast.
Here is a tip: Hum the BeeGees singing Stayin Alive when you do it, perhaps a little faster, not slower. Don't worry about popping ribs. Worry about pushing hard and fast. A compression with every beat of the song.

And get EMS there, fast.

Note: The most common reason for a child to have a collapse is RESPIRATORY, and there rescue breaths are useful.

HTH
CB

Pyekett
11-27-2013, 10:42 PM
Press Hard, Press Fast.
Here is a tip: Hum the BeeGees singing Stayin Alive when you do it, perhaps a little faster, not slower. Don't worry about popping ribs. Worry about pushing hard and fast. A compression with every beat of the song.

Or that classic dark side version, "Another One Bites the Dust."

*grin*

CoolBlue
11-27-2013, 10:47 PM
Or that classic dark side version, "Another One Bites the Dust."

*grin*

Now you're giving away trade secrets. ;)

And the prognosis of leaving the hospital with a reasonable life ahead. Not that good things don't happen.

CB

Pyekett
11-27-2013, 10:56 PM
(I tip my hat. ;) )

Lord have mercy, if only the success rate of CPR were within a level of magnitude of what you see on television or in the movies.

Now AEDs, that's another kettle of fish entire. Here is a truly good place to spend public money.

thethinker42
11-27-2013, 11:00 PM
Lord have mercy, if only the success rate of CPR were within a level of magnitude of what you see on television or in the movies.

Seriously. Every time someone magically wakes up--with intact ribs and generally no worse for the wear--after CPR, I facepalm so hard I nearly give myself a concussion.