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: Emergency Care of the Suicidal Patient

Riannon Asks:

I’d really appreciate your help in answering some questions. I’ve Googled as much as possible, and I just can’t seem to find answers for some things.

At one point in a play I’m writing, a character attempts suicide. His goal is not actually to die, but he does go through the process. What happens is that he’s very drunk and it’s a combination of probably alcohol poisoning and a lot of pills, something relatively accessible lying around the house, but potentially lethal in a high dose and then he calls 911 right afterwards.

So my questions are:
1. Would he be allowed to have visitors the next day? Essential for plot reasons.
2. Would visitors have to be family members or something or would friends/acquaintances be able to fudge their way in?
3. Before someone visits a patient, is the patient told that they’re coming and who they are? (I have very little knowledge of how hospitals work.)
4. How screwed up would he be physically?
5. Would he have to be committed to psych, and if so, when?
6. What could he have overdosed on?

Jordyn Says:

Hi Riannon!

Thanks so much for sending me your questions.

1. Would he be allowed visitors the next day? Depends on where he is at in the process. I’ll give you the process a patient goes through at our hospital, but you might need to adapt it if your play is located in a specific town, state, etc.

When a patient comes in with a suicide attempt, they are placed on 1:1 observation. The patient must be “medically cleared” before they can participate in a mental health evaluation. What that means is that they are no longer in danger medically from what they ingested AND that they are clear mentally to participate in the process. For instance, our patients would have to be below the legal limit for alcohol in order to participate. During the time of medical clearance and during the mental health evaluation (as for pediatrics parents are involved in the process) the patient is allowed to have visitors. A limited number. We try to keep it to two at a time and generally only immediate family.

If the patient is deemed to be a danger to themselves and does not voluntarily consent to treatment, then they are placed on an M1-Hold. This will have different names in different areas, but it is a legal document where the patient is involuntarily committed to a mental health institution for stabilization for about three days. Most mental health facilities will strictly limit visitors and may not let anyone visit during the initial 24-48 hours. Depends on the facility.

2. Could family/friends fudge their way in? I think I’ve mostly answered this above. If the patient is at a mental health hospital probably not without inside help. These are generally locked facilities that will keep a close eye on who is coming and going.

3. Is the patient notified of visitors? I can give you the ER answer and that is it depends. If the patient is unconscious then probably not. If the patient is conscious then we do want to inform the patient of who is there, but we would likely keep it to immediate family. We don’t want to inflame an already volatile situation so if the patient would become harmful to themselves or others then visitors are restricted. Pediatric patients will sometimes try and not have their parents visit, but parents are part of the process, so we encourage them to be at the bedside as long as the patient can be safe.

4. How screwed up would he be physically? Depends on a lot of factors. What he took. How much he took. And how long before he sought medical care.

5. Would he be committed to psych? If so, when? Yes, in this instance, he would be committed involuntarily if he did not agree to a voluntary admission. This would happen once he’s medically stable and after his mental health evaluation. Sometimes, patients may not be medically cleared for 12-24 hours (sometimes longer depending on the drug’s half life). Then we have to wait for an available mental health counselor which can take an additional 3-6 hours. Then waiting for placement could be another 3-24 hours. It can be a very lengthy process. Mental health beds are not that easy to find at times. Patients are held in the ER until they have a bed placement. It is also a requirement of our hospital that patients be transported by ambulance to their mental health facility and generally family members are not allowed to ride in the ambulance with them. This is a safety concern for the EMS crew.

6. What could he have overdosed on? This is really up to you as the author. Any drug can be toxic given in enough quantities and alcohol ingestion on top of that can make things much worse. Some of the more common medications most people have at home that can become easily toxic, in my opinion, would be acetaminophen (Tylenol), aspirin, and diphenhydramine (Benadryl).

Hope this helps and best of luck with your novel!

Plants: Poisons, Palliatives and Panaceas Part 2/2

Author Kathleen Rouser returns to discuss the historical use of plants for medicinal and not so medicinal purposes. You can find Part I here.

Plants: Poisons, Palliatives and Panaceas
Part II

 

Foxglove/Anne Burgess

From the Middle Ages onward, medicinal plants grown by wives and mothers for their families were referred to as “simples”. One of them, foxglove, had been used to treat many maladies, even tuberculosis. By itself, ingesting a single leaf of foxglove can cause immediate heart failure. But housewives learned how to use digitalis, the drug derived from foxglove, as a stimulant for the heart. By the late 18th century, an English doctor recorded that digitalis would strengthen an ailing heart. Today, digitalis is often prescribed to treat heart failure, regulating the heartbeat and strengthening the cardiac muscle.

 

Deadly Nightshade/David Hawgood

 

Another poisonous plant, deadly nightshade, grows berries that can be fatal if eaten. Larger pupils were considered more attractive during the Middle Ages, so drops of juice from this fruit were once used to dilate the pupils of young women. It was called “belladonna”, meaning “beautiful woman” in Italian. Today, atropine is produced from deadly nightshade, to dilate patients’ pupils, so eye care practitioners can further examine their eyes.

American frontier families carried dried simples, some of them familiar to us as food seasoning, such as marjoram or thyme. They believed tasty sassafras would purify or thin the blood.

A popular tonic once used by mothers and prescribed by doctors in the nineteenth and early twentieth centuries was derived from the castor bean. A powerful laxative, castor oil cleansed the bowel, a treatment often used to cure whatever ailed you.
In ancient times Hippocrates warned against the use of opium, a painkiller made from the milky juice of poppies, because of its powerful addictive properties. This didn’t stop mankind from using it, whether to develop dangerous drugs such as heroin or pain relieving narcotics. In the 1660s, the English physician Thomas Sydenham produced laudanum from mixing opium with wine and saffron. This painkilling drug was used into the twentieth century. During the earlier 1800s, both the powerful narcotic morphine and the less potent codeine, were first made from opium extracts.

 

Willow Tree

As chemists learned how to extract and isolate chemicals in plants, they found just which components actually worked. German chemists were eventually able to analyze the bark of the willow tree. From ancient times extracts of willow bark had been used to reduce fever and relieve achiness, but not until 1899 was it known that the active ingredient was salicylic acid. Yet, decades passed before they figured out how this active ingredient, we know as aspirin, worked!

The shelves of our local health food stores are filled with herbs and ingredients made from many different plants. Some of these are based on folk remedies, proven successful throughout history, while others are yet unproven. Who doesn’t enjoy the soothing calm brought to one’s nerves through a cup of chamomile tea on a cold winter’s eve? Or settled an upset tummy with ginger ale or peppermint tea?  God knew what He was doing when He provided us with curative and nourishing plants—plants that we even derive many helpful and healing pharmaceuticals from today.

Thanks so much, Kathleen, and be sure to check out her forthcoming multi-author novel, The Great Lakes Lighthouse Brides Collection, releasing November, 2018

Plants: Poisons, Palliatives and Panaceas Part 2/2: Click to Tweet.

*Originally posted May, 2011.*

Resources:

Court, William E. “Pharmacy from the Ancient World to 1100 A.D.

Making Medicines: A Brief History of Pharmacy and Pharmaceuticals. Ed. Stuart Anderson. London, UK: Pharmaceutical Press, 2005. 21-36. Print.

 

Facklam, Howard and Margery. Healing Drugs: The History of Pharmacy. New York: Facts on File, Inc., 1992. Print.

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Kathleen lives in Michigan with her hero and husband of over 30 years. First, a wife and mother, she is “retired” after 20 years of home educating their three sons, who are all grown and have moved away.  Kathleen has been published in Home School Digest and An Encouraging Word magazines. She writes regularly for the local women’s ministry “Sisters” newsletter. She also contributes articles and author interviews to Novel PASTimes, a blog devoted mostly to historical fiction. You can connect with Kathleen via her website.

 

Plants: Poisons, Palliatives and Panaceas Part 1/2

I’m very pleased to host Kathleen Rouser as she guest blogs about her research into historical pharmacy.  This is excellent information for both the historical and contemporary writer. I know your plot wheels will turn with this information.

Welcome, Kathleen!

Plants: Poisons, Palliatives and Panaceas
Part I

Then God said, “I give you every seed-bearing plant on the face of the whole earth and every tree that fruit with seed in it. They will be yours for food.” Gen. 1:29 NIV

 

Shortly after the time Adam and Eve were forced to leave the Garden of Eden, because of their fall into sin, human beings most likely began looking for relief from pain and sickness. Perhaps by God’s guidance or by what seemed like coincidence, they found that there were certain plants that not only nourished, but also relieved symptoms or cured illnesses.

Throughout the ancient world healers emerged, whether as a medicine man, priest, wise woman or physician. They were brave enough to search by trial and error to find the right cure for each malady. These practitioners, whether spurred on by superstition or curiosity, had to figure out which plants healed… and which ones harmed. The line between healing and poisoning was often quite fine.

A few of the remedies the Sumerians used were made from licorice, myrrh, mustard and oleander. The Code of Hammurabi, originating during his reign (1795-1750 BC), regulated medical practice. There, apothecaries emerged, since the role of preparing medication was considered separate from that of the physician.

 

Poppy Plants

Around 1500 BC, the Egyptians wrote a dissertation on medicine and pharmaceuticals. Among many plant sources they derived their drugs from were castor seed, spices, poppy and acacia. They imported some ingredients due to the limitations of what they could grow. The Egyptians developed ways to dry, ground up and weigh these materials. Those that concocted medicines were called ‘pastophors’ and were members of a priestly profession.

Seventh century BC clay tablets have been discovered revealing that the Babylonians used many plants as pharmaceuticals including castor seed, thyme, peppermint, myrrh, poppy and licorice.

Various theories of diagnosis and treatment arose through the Greek and Roman civilizations. Pedanius Dioscorides, who lived from around 50-100 AD, wrote Materia Medica, which listed various materials with their medicinal uses and also Codex Aniciae Julianae. This text on herbals, listed many plants and how to prepare them through drying and extraction. Dioscorides, a surgeon to the Roman armies, shared a philosophy with another famous Roman medical man, Galen. They believed that each plant’s shape, color or other physical characteristics left a clue as to which body part or ailment it was meant to treat. By the 16th century, this was foundation to one Christian viewpoint, which had expanded upon the Doctrine of Signatures, stating that it was the Creator who had marked each of these plants for their use.

During the Dark Ages, the Arab world and the monasteries of Europe, with their healing gardens, preserved much pharmaceutical knowledge.

Throughout history, many folk remedies, based on superstition, were supplemented with chants and rituals. Most often they missed the mark, perhaps imparting comfort if nothing else, considering man’s need to feel as though he is doing something! But apart from that, many plants continued to be used for healing and a large proportion of modern day prescription drugs are rooted in their derivatives. Some emerged to the forefront.

 

Cinchona Tree

During the 1600s, European Jesuit missionaries in South America sent a powder back home, derived from the bark of the cinchona tree. They’d been surprised to find out that the Native Peruvians knew how to successfully treat malaria, an illness spread by mosquitoes that has killed so many. In 1820, when French chemists extracted a chemical compound from the powdered bark of the cinchona tree, they called it quinine, based on the Peruvian name for the tree, quinquina.

William Clark and Meriwether Lewis took cinchona bark with them on their westward expedition. Lewis’s mother was an herbalist of some renown and imparted some of her knowledge to her son. While the men did not wind up contracting malaria, they found the bark useful for lowering fevers and as ingredient in poultices.

Would you like to know what “simples” are? And what potentially poisonous plants are used in pharmaceuticals today? Come back for Part II and find out!

Plants: Poisons, Palliatives and Panaceas Part 1/2: Click to Tweet

*Originally posted May, 2011.

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Kathleen lives in Michigan with her hero and husband of over 30 years. First, a wife and mother, she is “retired” after 20 years of home educating their three sons, who are all grown and have moved away.  Kathleen has been published in Home School Digest and An Encouraging Word magazines. She writes regularly for the local women’s ministry “Sisters” newsletter. She also contributes articles and author interviews to Novel PASTimes, a blog devoted mostly to historical fiction. You can connect with Kathleen via her website.

Dear Medical Thriller Author: Please, Ask a Nurse

I just got done reading a recently released medical thriller by a well known author. The novel, overall, was really enjoyable. Truly a captivating story line. However, there is one medical scene that continues to bug me because of the medical inaccuracies that could easily be solved by having a nurse with expertise in the area read over the scene.

In the last three medical thrillers I’ve read, the author always notes the doctors that helped with the novel, but I honestly don’t think I’ve ever heard a nurse mentioned. Trust me, they needed a nurse. Our expertise is in delivering the medical care as ordered by the physician so we know what makes sense and what doesn’t.

In the scene, the patient is suspected of ingesting the poisonous mushroom Amanita Phalloides also known as the Death Cap. The patient has potential political fallout so our hero, a family practice physician, is designated as team leader for this code over two ER physicians. I’ll discuss some of the things I find problematic with the scene.

The hero admits he’s not an expert on mushroom toxicity, but doesn’t phone a friend. One of the first things that should be done in addition to providing for the patient’s medical needs is consulting a toxicology expert (a poison control center is a great place to start). In toxic ingestions of any kind, the medical team needs to know how to counteract the poison. This targeted therapy may be the only thing that will save the patients life. Even if the patient is provided stellar medical interventions, if they’re not given the antidote, it will all be in vain and the patient can proceed to death. That being said, not every poison has an antidote, which then means supportive care.

Let’s discuss these two statements from the novel:

“BP is sixty over palp,” said a nurse, taking the measurement by palpating with her fingertips.
“Pulse one forty-eight by monitor. I can’t even feel a carotid pulse.”

First of all, taking a palpated blood pressure is not usual in the hospital setting. This is typically done by EMS as a quick and dirty measure for obtaining a BP because it is really hard to hear through a stethoscope with sirens blaring above you. Next thing is, one of these two people are wrong. A carotid pulse is considered a central pulse so if it can’t be palpated then the patient is pulseless, has no BP (because you need a palpable pulse to have a BP), and therefore requires CPR no matter what is seen on the monitor. This rhythm is called pulseless electrical activity (PEA) and is treated medically like the patient is asystolic or flatlined. Treatment is high-quality CPR and IV epinephrine, but our hero calls for a central line.

Then there’s this statement:

“Right now, D-five normal saline at two hundred an hour. Wide open.”

D-five normal saline is an IV solution. This is typically not given in a code situation which I won’t highlight here. In reading about this mushroom’s toxicity, I get why the author chose this IV solution, but the reader doesn’t know and so it should be spelled out what the doctor is worried about clinically for this ingestion and how he’s going to treat it.

However, what’s really wrong with this statement is that it is a contradiction in terms for the nurse. Either the rate is 200 ml/hr or the rate is wide open which means the IV bag is let to run into the vein via gravity as fast as it will go. In an adult patient, the IV bag could be delivered in as little as five minutes depending on the size of the IV catheter that’s been placed.

Lastly, this gem:

“Compressions at ten per minute.”

There is a lot wrong with this medical scene (too much to blog about here), but this is by far the most egregious. I read this to my accountant husband and even he knew this was not medically correct. In fact, I googled, “How fast should you do CPR?” and it gives the correct answer without having to click into a web site which is 100-120/minute. This can’t even be a typo because one hundred and ten— can you really mistype that?  Flat out, this is an easily researched aspect and there is prolific information out there on doing CPR.

Dear Medical Thriller Author: Please, Ask a Nurse Click to Tweet
What’s Wrong with this Medical Scene? Click to Tweet

Just as I ask doctors about the medical accuracy of my scenes, so should nurses be asked. Particularly those who are actively practicing in the area.

9-1-1 S1/E3: Evaluation and Treatment of Overdoses

In Episode 3 of 9-1-1, the story opens with officer Athena Grant, played by Angela Bassett, finding her daughter unconscious from taking hydrocodone pills as seen in the trailer below. The daughter, who appears to be between twelve and fourteen, is whisked off to the hospital and admitted to the ICU in short order. One, did they treat this ingestion (or overdose) correctly? Two, would this type of ingestion warrant ICU admission?

It’s stated in the episode that the daughter took “six to seven” hydrocodone pills. Hydrocodone is a combination of acetaminophen (Tylenol) and a synthetic type of codeine. It comes in many different preparations with different amounts of acetaminophen and hydrocodone. Where do we start to evaluate whether or not the ingestion is worrisome?

1.  How is the patient? What signs and symptoms do they have?  The EMS crew in this situation is lucky. The mother knows exactly what the daughter took. She presents unresponsive with slow breathing. Number one treatment in this situation after assisting with her breathing? Give Narcan which this crew absolutely does not do. Narcan is a reversal agent for opioids. It can be given via a mist up the nose so you can generally reverse the sedative effects of the drug without even starting an IV. It is a life saving measure because it is the not breathing part that will kill you first. This is the medication they should have given first.

In absence of knowing exactly what the patient took, we can look at clusters of signs and symptoms called toxidromes which might point us in the right direction.

2. What did the patient take? When did they take it? How much did they take? Many drugs have multiple components and we have to evaluate EACH component and whether or not this could prove harmful to the patient. The opioid  (once reversed with Narcan) is probably the least concerning. The amount of acetaminophen ingested is our next priority and we would calculate how many milligrams per kilogram she took. We know for acetaminophen that when you start to get between 100-150mg/kg that there could be a potential for liver damage. There is a reversal drug for acetaminophen’s damaging effects on the liver called Mucomyst, but there is a window in which this can be given to be effective. Usually, a poison control center will help us manage these types of patients.

In this case, let’s say she took six pills of Lortab 7.5/500. From this we know that each pill has 500mg of acetaminophen. Assuming the average 12-14 y/o is about 100 lbs (converted to 45 kg) then she took about 66mg/kg of acetaminophen. A four hour Tylenol level (measured four hours after the ingestion) would be checked to ensure she wasn’t toxic, but in this case likely not.

3. Will this patient be admitted to the ICU? It might come as a surprise, but ingestions of medications are most often not admitted to the ICU. Most are managed and observed in the ER. In this case, the girl should have been given Narcan by EMS. We would continue to watch for the somnolent effects of the opioid and evaluate the risk of the acetaminophen.

Also, it’s generally protocol that an aspirin level is measured as well even if the patient denies taking any. We can’t always depend on the patient being truthful about what they took and aspirin can have very devastating effects as well. Other labs depend on the medication ingested and what parts of the body if affects. This patient would likely not be admitted to the ICU.

Also, if we get a toxic ingestion within an hour we can give activated charcoal (that literally looks like black sludge) that will bind the medication. This is not always done for several reasons. One is the risk of the charcoal ending up in a patient’s lungs during administration. Usually this is done under the recommendation of Poison Control.

4. Do we notify Child Protective Services? In this episode, Child Protective Services conducts a mental health exam on the teen. In the real world, this evaluation takes place through mental health providers not associated with the state. State involvement is generally reserved for what we would consider a risky home environment. A teen getting into their parents medicine cabinet for some pills would not fall into that category. What would? A two-year-old ingesting crack cocaine that was lying around the home. Each case is handled very individually, but this case presented in 9-1-1 would not rise to that level in my opinion.

As a side note, parents are not separated from their children during medical treatment. Can we please stop perpetuating this myth?

What do you think of 9-1-1?

Critical Care Toxicology: What Did My Patient Take? 1/2

Surprisingly, patients aren’t entirely truthful about what they may have ingested to make them sick. Or, they might be in a state where they can’t share the information due to their medical condition. This can put the medical team in a worse case scenario where if they knew what the patient took . . . they might be able to offer the right antidote.

Without the information it can seem like a shot in the dark to try and reverse the effect the substance is having on the individual.

Recently, I heard a fascinating lecture given by a doctor of toxicology who gave some guidelines, based on the patient’s signs, as to what that drug might be and I thought I’d share them with you for some great writing details.

Let’s first assume that we at least know the patient likely ingested something. They’re discovered by EMS in their home with an array of alcohol, pills, and drug paraphernalia. A good EMS team will try and take stock of what they see and report to the ER what they found. They’ll likely not grab illegal drugs like weed or powders (this would be for the police to confiscate) but they may bring unidentified pills and prescription bottles to help us. This can help narrow down what the person might have taken.

The opposite is finding someone unconscious in the middle of the street with nothing around them and the police call EMS for transport.

Or, even better, a teen has been involved in a “pharming party” where they raid every medicine cabinet they have access to and dump all they find into a punch bowl. Then proceed to swallow a handful of these pills with a bunch of alcohol. I have had cases like this where EMS grabbed the bowl and brought it with them. I mean, a punch bowl filled with prescription drugs but no boxes or labels. Even if we have the pills– it takes time to identify what they might be.

Time the patient might not have.

Scenario #1:

The patient presents with low heart rate and low blood pressure.

First, why would we think this may be a drug ingestion? The body’s normal response to low blood pressure is to increase your heart rate– not lower it– as a mechanism to prevent shock.

There’s only one other medical state I can think of that would mimic this and that would be a spinal cord injury. When the spinal cord is damaged, you lose nerve innervation that would help increase blood pressure. So, in absence of a traumatic event, a spinal cord injury would be ruled out. However, an unconscious person can’t tell us if they’ve been injured which further complicates the picture.

Drugs that can create this picture could be the following:

1. Beta-blocker. Your heart has beta receptors. When these are stimulated, say by a release of adrenaline in your body, the heart contracts harder and beats faster. A beta-blocker “blocks” these receptors so the opposite happens. Propranolol is beta blocker.

2. Clonidine. Clonidine is a sympatholytic medication meaning it blocks the flight or fight response. It’s used to treat high blood pressure but also ADHD and anxiety disorders. Personally, I’ve seen quite a few of these ingestions and they tend to be very unpredictable. The child can be fine one minute and then, with little warning, have a very slow heart rate and be unarouseable.

3. Baclofen: A muscle relaxer.

4. Calcium Channel Blocker. These drugs do what they say– block the flow of calcium from entering heart cells and those that line your blood vessels. Calcium acts to contract things so blocking its flow has the opposite effect. They are used to treat high blood pressure, migraine headaches and Raynaud’s disease. Verapamil would be a drug in this class.

5. Digoxin: I talk extensively about digoxin toxicity in this post.

How do we treat? With the exception of digoxin, there is no specific antidote so it is largely symptomatic support.

1. Give IV fluids. This will help support and raise the blood pressure.

2. Give Calcium. This helps things contract– thereby raising the blood pressure as well.

3. Give a Vasopressor. Vasopressors work to contract blood vessels to raise blood pressure. These would be drugs like dopamine and epinephrine (adrenaline).

There are a few other things to be done but this will give you plenty to write a scene that involves this type of drug ingestion.

Have you written a medical scene that dealt with a drug overdose in your novel?