Author Question: Help Me Knock Out My Character!

Elizabeth Asks:

I need to temporarily drug character. She will ingest it unknowingly (probably through coffee). I’m also considering having her drink one glass of wine, so the culprit could be the drug itself or the combination of the two, but I’m open to other possibilities.

It would need to be an OTC drug or something with easy access. Also, the drug would either have to wear off on its own or need be handled by an EMT without access to a hospital or medical equipment. What drug would get the job done? Would sleeping pills work and if so which kind would be best? How much would the character need to ingest? And how long before it takes effect and wears off?  Thank you!

Jordyn Says:

Hi Elizabeth!

Thanks for sending me your medical question.

You specify that the drug would need to be over-the-counter or something with “easy access”. Your two possibilities would truly be something over-the-counter or a prescription medication is stolen from someone else.

There are plenty of over-the-counter medications that cause sleepiness. The three most common would probably be diphenhydramine (Benadryl), dimenhydrinate (the active ingredient in the Dramamine that causes sleepiness), and doxylamine succinate. Several combination medications contain these active ingredients. For instance, if you look at multi symptom cough medicines, you’ll likely see one of these medications. Same with Tylenol PM or Advil PM. To a lesser degree, Melatonin and Valerian Root can also cause drowsiness.

The problem with all of these over-the-counter preparations is that they don’t have the same predictable impact. One person might take one of these medications and fall asleep in fifteen minutes. Another might take it and not be sleepy at all.

A safer bet would be to have this character steal a prescription medicine from someone. This opens up your possibilities of what drug to choose that would have a more predictable effect. Some of those drug categories would be benzodiazepines (such as Valium and Xanax), opioids (like morphine and fentanyl), and the hypnotics (like Ambien and Lunesta). Also, muscle relaxers like Soma and Flexeril have sleepiness as a side effect.

Then, of course, your character could obtain an illegal drug like Ketamine or GHB (aka the date rape drug).

The OTC medications will probably have the least disastrous side effects if given in normal doses. Your chances of injuring your character go up exponentially with these other drug classes if proper medical attention isn’t give if the character stops breathing. This would be the leading cause of medical calamity using a prescription or illegal drug.

In the end, it’s up to you to decide. I think the best thing for you to do would be pick a drug from each of these classes: over-the-counter, prescription, and illegal— and research a few to decide. If you type in the exact name of the drug and the question you want answered (like dose, onset of action, etc) you will usually find drug guides that can answer these questions for you.

Hope this helps and good luck with this story!

Author Question: Drug Dosing in Super Human Metabolism

Racheal Asks:

I’d love to hear your thoughts on the topic of medicine and dosage within the context of someone with super-human levels of heightened metabolism. Obviously, the concept pushes the question dangerously towards completely fictional answers, but I’m hoping for any input you have at least in the abstract. For instance, would you give the patient more concentrated doses, more frequent doses, larger doses?  What kind of medicines would be prescribed/would correlate with the metabolism bit in context of painkillers and treatment of a gunshot wound?

Jordyn Says:

Regarding your question surrounding metabolism– I think both could be true that the patient may need to receive higher doses and be dosed more frequently depending on the half life of the drug. Fentanyl and Versed could be two of the drugs given for chest tube placement– one for pain and one so the patient doesn’t remember the procedure. These would be given if the patient is fairly stable with good blood pressure. You could look up these drugs and see how fast the peak. Peak time is when the patient will be under the full effects of the medication. From that, you could put in whatever metabolism rate you wanted (2X, 3X or faster) and be able to determine how much more quickly they would need to be redosed on the medication. Also, you could look at the drugs half-life. Half-life is when 50% of the drug is metabolized by your body. You could look at this number, factor in their sped up metabolism rate, to also know how frequently they might need the drug.

You can ususally research this on-line fairly easily by searching for drug information sheets. I’ve included one here for Fentanyl.

I thought this would be a great question to run by Sarah Sundin who is a fabulous author and real life pharmacist. I hope you check out her wonderful historical novels set during WWII.

Sarah Says:

A higher metabolism would lead to a higher clearance — shortening the half-life of the medication. That would mean increasing the frequency for dosing from every twelve hours to every eight hours or every six hours. Often that means an increase in dose as well. Of course, we have to clarify “metabolism.” Some drugs are cleared by the kidneys (renally) and some are cleared by the liver (hepatically) and most are a combination of both. Whatever function you speed up for your character would have to match the primary method by which that medication is cleared.

To research how a drug is metabolized in the body you would search for “pharmacokinetics of Fentanyl” as an example. These articles would help you determine by what method in the body the drug is cleared.

Hope this helps and good luck with your story!

Author Beware: Doctors Cannot Do Everything

I was recently reading a YA novel (that I did really enjoy BTW) when I came across this passage. For a quick background, this young girl has just woken up screaming after being involved in a car accident so it’s presumed she has a head injury.

The passage is as follows from the novel:

The room fills up with people. Two nurses and a doctor appear as quickly as if I’d pushed the little red call button on my bed. 

“Sophie, I’m Dr. Langstaff. You’re in a safe place and I’m here to help you.” The doctor holds a syringe and a container, measuring out a clear liquid. “I’m going to give you some medicine to calm you down and help you sleep.” He inserts the syringe so the medicine flows into my IV. It drains the screams right out of me, like he’s pulled the plug on my lungs.

Interestingly, there are quite a few problems with this small passage.

1. There is a process to giving medications in the hospital. The doctor orders the medication, the pharmacy double checks and approves the dosage, and the nurse draws it up and gives it to the patient. This patient is on a medical surgical floor— this is the process that would take place.

2. Doctors generally don’t have access to sedatives or narcotics. There are only a few areas in the hospital where a doctor would have direct access to these types of medications that they could pull themselves and that would be anesthesia. Narcotics are very tightly controlled. Doctors generally can’t even access narcotics or sedatives via the medication dispensing machines on the floor— even those medications that only they can give (such as perhaps Ketamine for a sedation). This is not the “old” days where a doctor carried around a stock of medications he could dispense. Nowadays, they likely can’t even access them.

3. Sedatives generally aren’t the first choice for a distressed patient.  I think for writers, this idea comes from watching too many bad television hospital dramas, but in real life is rarely done. The first step in handling a patient that first wakes up from a traumatic event is to orient them to where they are and what’s happened. Involve the family in helping them feel safe. If the distress continues, evaluate if there is a medical reason behind it. Is there some undiagnosed medical problem? Does she need a repeat scan of her head? It really is unusual that you can’t calm a person down— even one with a head injury. Patients are generally only given sedation if they become physically harmful to themselves or others. We do use sedation in some of these situations, but not as a first line and not as often as you might think and most likely not in the head injured patient.

What are some other things you’ve seen in books that aren’t accurate as far as a hospital setting goes?

Author Question: How Fast Does A Tranquilizer Dart Work?

Alyson Asks:

I’m writing a script where the villains shoot people with a gun but we discover later it was only a tranquilizer. Is there a tranquilizer drug combination that can be shot from a distance (can be close range) at a person that would take effect fairly immediately? Or would stop them from being able to communicate immediately.

Jordyn Says:

Thanks for sending me your question.

There is no drug combination given intramuscularly (IM or within the muscle as a dart injection would be) that would incapacitate a victim immediately or even within a few seconds. For instance, Ketamine takes 3-4 minutes to work IM. This will be the case with most drugs given via this route— the range of 2-4 minutes for onset of action.

Hope this answers your question.

Best of luck with your story.

Author Question: Drug Injection Scene

Kiri Asks:

I really hope you can help me. I feel like I’ve reached out to half the medical community and still haven’t gotten an answer.

I have a protagonist who suffered a ruptured aneurysm two years before the story starts. The aneurysm caused a stroke. Presently, he is mostly recovered, though he still suffers migraines and some memory loss. I have a scene where another character catches sight of yet another character giving my protagonist a shot in the arm.

Originally, I had the intramuscular injection be a vasopressor to help with his blood pressure, but then someone told me this would only be done in a hospital.

I would really like to keep this injection scene. So I changed it to an anticoagulant, though I’m having trouble verifying that this is anything someone like him might need. (Did I mention he has another blood vessel wall bulging and ready to burst, this one inoperable?)

I also have him taking beta blockers for his migraines and he later uses these to try to commit suicide by taking an entire bottle. An ER nurse told me this would certainly be dangerous. I could change it to another drug.

Any thoughts are much appreciated.

Jordyn Says:

First of all, you have two competing medications. A vasopressor raises blood pressure and are typically given IV in the ER and ICU setting. The beta blocker used for his migraines can (and often does) lower blood pressure.

Unfortunately, I don’t see either of your two options as feasible for an intramuscular injection scene— either as an anticoagulant or a blood pressure medication. If the character’s blood pressure is too low, the first thing would likely be to give him some IV fluids and just stop the beta blocker.

Some patients do go home on subcutaneous (SQ) anticoagulant therapy, but usually it’s when they have a known clot— not simply to just keep the blood thin. There are too many excellent prescribed oral medications to do this on an outpatient basis. If you wanted your patient to have a clot in the leg (deep vein thrombosis) than this therapy would be reasonable but developing a clot like this would be unlikely if he were already on anticoagulants for his brain coils related to treatment of his first aneurysm. You could read more about this here.

I’m not aware of any blood pressure medicines that are given SQ or IM (into the muscle). There are several given IV in the emergency/ICU setting but these would not be appropriate for home use. Patients are transitioned to home oral medications.

The only medication that could be given consistently SQ on a home basis with any regularity that I could see would be insulin for diabetes.

I did find this pamphlet on-line about SQ meds given in palliative care (hospice) but I don’t think any would fit your scenario. They are mostly anti-anxiety, anti-nausea, or drying agents for secretions given this way because the patient can’t swallow anymore. In fact, most of the links about SQ meds given at home were in conjuction with hospice care.

Also, SQ and IM sites and the angle at which they are given are different as well.

Probably best to find an alternative to this scene.

Author Question: Is There a Drug that could Mimic Death?

Toni Asks:

I’m writing a contemporary retelling of Snow White. I was wondering if you have any suggestions on how the stepmom could intend to poison her but is not successful. Instead, maybe just paralyzes her or slows her respiratory system down to where it seems she’s dead. Any suggestions?

Jordyn Says:

I brainstormed this with a co-worker pharmacist and these are our thoughts.

There isn’t a current paralyzing agent that will work for this scenario. A couple of problems with paralyzing agents is that they never just slow down respirations— they knock them out totally. Plus, in the absence of a sedative, the person is very much awake and panicked because they can’t breathe. Giving this drug alone could not mimic death and would rapidly cause death from hypoxia unless medical intervention was given post haste.

The drug we came up with for you is called Donnatal and can be given as an elixer. It has four medications: Hyoscyamine, Atropine, Scopolamine, and Phenobarbital. The hyoscyamine actually helps with intestional disroders like irritable bowel syndrome. It is the other three components that will help with your scenario.

The atropine and the scopolamine both act to dilate pupils and could mimic fixed and dilated pupils that you get upon death.

Phenobarbital is a barbiturate and can be used to treat anxiety and seizures. Overdosing on phenobarb will cause slow and shallow breathing.

Here is a patient teaching sheet for further information.

Hope this helps and best of luck with your story!

Pharmacy in World War II: The Military

Sarah Sundin concludes her series today on WWII and the role of the pharmacist. Wasn’t the information amazing? You can find Part I and Part II by following the links.

Welcome back, Sarah!

While researching the military medical system for my World War II novels, I read about physicians and nurses, dentists and veterinarians. But where were the pharmacists? In the civilian world, the physician prescribes medication, the pharmacist purchases, compounds, and dispenses, and the patient or nurse administers. I discovered the wartime military system differed. As a pharmacist I was baffled and intrigued.

On February 14th, I discussed the role of the pharmacist in the 1940s. On February 16th, I described the local drug store and how its role changed during the war, and today I’ll review the rather shocking role—or lack thereof—of pharmacy and pharmacists in the US military.

Drug Distribution in the Military

In the US Army and Navy, outpatient prescriptions were filled at base or unit dispensaries, while inpatient orders were filled at hospital pharmacies. Both dispensaries and pharmacies were staffed by enlisted personnel—pharmacy technicians in the Army and pharmacist’s mates in the Navy—under the control of physicians. In 1936, the pre-war Army had forty graduate pharmacists serving as enlisted technicians.

Pharmacy technicians did not need any previous health care background or education. They went through a three-month program based on practical training rather than scientific understanding.

Medical Administrative Corps

For decades, pharmacy organizations had lobbied for a Pharmacy Corps with commissioned pharmacists. Indeed, most nations had similar corps. However, the US Army Medical Department was run by physicians. They thought of pharmacists in a condescending manner as businessmen rather than professionals, and they saw the drug distribution system as adequate.

The Medical Administrative Corps was formed in 1920 as a compromise. The MAC was responsible for administrative duties within the Medical Department, including medication procurement and distribution. In 1936, the MAC was permitted to commission sixteen pharmacists, with future appointments in the MAC restricted to graduate pharmacists.

The number of officers in the MAC increased during the war. In 1943 six hundred graduate pharmacists served as MAC officers—but none of them served as pharmacists.

Options for Pharmacists

Since most draft-age pharmacists had four-year bachelor’s degrees, they were eligible to serve as officers. While physicians, nurses, dentists, and veterinarians were commissioned as officers and placed in appropriate positions, no such guarantee was available for pharmacists.

Upon enlistment, pharmacists could apply for the Army Officer Candidate School, but upon graduation, they could be assigned anywhere. Pharmacists served as infantry officers, artillery officers, and in many other divisions. Even if they happened to be assigned to the MAC, as noted above, they did not practice their profession.

If a pharmacist wanted to compound and dispense medication, his only option was to serve as an enlisted technician, with pay and privileges far below that of an officer.

Fight for a Pharmacy Corps

The American Pharmaceutical Association (APhA) renewed the legislative battle for a commissioned Pharmacy Corps. While the Surgeon General’s office argued that “Army pharmacy was simpler than civilian practice. The department’s three-month pharmacy technician course was sufficient preparation. There was little compounding. Since medications were furnished in tablet form, ‘any intelligent boy can read the label’” (1).

These arguments did not sit well with pharmacists—or with the general public. Dr. Evert Kendig of the APhA argued that “Army pharmacy technicians were given responsibility beyond that legally permissible in civilian life even as the Army misused its professional pharmacists” (1). Several incidents were reported of prescriptions improperly filled by technicians and of blatant physician prescribing errors that would have been caught by a pharmacist. Public opinion tipped the scale, and on July 12, 1943, President Roosevelt signed legislation authorizing the formation of the Pharmacy Corps.

Pharmacy Corps

The Pharmacy Corps was authorized to commission seventy-two pharmacists. However, the military moved slowly. In January 1944, after receiving 900 applications and conducting two-day written examinations, physical examinations, and interviews, twelve officers were commissioned. By January 1945, the Pharmacy Corps had only commissioned eighteen pharmacists. The other officers’ slots were filled by former MAC officers.

The drug distribution system did not change by the end of the war, but the formation of the Pharmacy Corps laid the groundwork for post-war reforms.

Resources:

  1. Ginn, Richard VN. The History of the US Army Medical Service Corps. Washington DC: Center for Military History, 1997. (Accessed February 6, 2011 at http://history.amedd.army.mil/booksdocs/HistoryofUSArmyMSC/msc.html).
  2. Worthen, Dennis B. Pharmacy in World War II. New York: Pharmaceutical Products Press, 2004.

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Sarah Sundin is the author of the Waves of Freedom series (Through Waters Deep, 2015, Anchor in the Storm, 2016, and When Tides Turn, March 2017), the Wings of the Nightingale series, and the Wings of Glory series, all from Revell. In addition she has a novella in Where Treetops Glisten (WaterBrook).

Her novel Through Waters Deep was a 2016 Carol Award Finalist, won the 2016 INSPY Award, and was named to Booklist’s “101 Best Romance Novels of the Last 10 Years.” Her novella “I’ll Be Home for Christmas” in Where Treetops Glisten was a finalist for the 2015 Carol Award. In 2014, On Distant Shores was a double finalist for the Golden Scroll Awards from both AWSA and the Christian Authors Network. In 2011, Sarah received the Writer of the Year Award at the Mount Hermon Christian Writers Conference.

A mother of three, Sarah lives in northern California, works on-call as a hospital pharmacist, and teaches Sunday school and women’s Bible studies. She enjoys speaking to community, church, and writers’ groups, and has been well received.