#atropine mechanism

[flickeringflame216]

they should pay me to ask questions no one knows the answer to and then research the answers

[prof-dr-crane]

Hello Dr. Crane

Out of curiosity would you mind sharing some of your discoveries with fellow psychologist, mostly I'm curious about usage of adrenaline and noradrenaline in your tests. If you used them at all that's, but I suspect they they easiest way to put human into flight-or-fight response. Did you noticed any difference depending on which one you used, specially which one or mix of two cause patients to hallucinate longer?

Also did you ever was punch during your testing as patients turn out to have strong fight response? 

Ah, a fellow psychologist. A rare occurrence, and a welcome reprieve from the usual rabble.

Your hypothesis is a logical one, adrenaline and noradrenaline are, indeed, fundamental in the induction of the fight-or-flight response. However, they are blunt instruments. Crude, imprecise. A scalpel is always preferable to a hammer.

While I have experimented with direct administration of these catecholamines, I find their effects to be fleeting, their influence dictated more by individual metabolic rates than by any reliable chemical mechanism. Adrenaline, for instance, surges rapidly, spiking heart rate, dilating bronchi, and priming the body for immediate action, hardly conducive to prolonged hallucinatory states. Noradrenaline, though longer-lasting, is more selective in its activation, its primary role being vigilance and sustained alertness rather than the raw, unbridled terror I require.

Instead, my formulations favor agents that modulate the body's own neurochemical responses rather than forcibly induce them. Scopolamine and atropine, for example, interfere with acetylcholine transmission, disrupting memory encoding and sensory processing, making hallucinations more immersive and disorienting. Monoamine oxidase inhibitors, when used as potentiators, extend the presence of key neurotransmitters, ensuring a more prolonged and profound experience.

Of course, should one introduce both adrenaline and noradrenaline in a controlled ratio, the results become more… chaotic. The subject’s body struggles between the immediacy of action and the endurance of sustained hyper-awareness. The outcome? Disorientation, exhaustion, and in some cases, complete physiological collapse. An inefficient method, but an effective reminder that fear is as much about endurance as it is about intensity.

To your second question: Indeed, during my experiments, particularly with subjects exhibiting pronounced fight responses, I have experienced physical confrontations. Notably, the Dark Knight's resilience often led to such... unpleasant interactions.

- Dr. Jonathan Crane

[justkidneying]

What kind of critical care medications are available to use on a patient? What makes them work?

Thanks for the ask! There's dozens of meds I've seen used in critical care situations, so I will just go through a few of them that I think are most helpful.

Nitroglycerin is used when patients are having a hypertensive crisis. It comes in little pills that they put under their tongue (sublingual administration). The body breaks this down to make nitric oxide. This is the same thing that your body makes when you need to lower your blood pressure. The endothelium of your vessels makes this, and can be signaled to do so by several molecules and transmitters. This vasodilates, lowering blood pressure and allowing tissue to be perfused better.

Albuterol is a bronchodilator that is used to treat asthma and COPD. It is typically inhaled. This is a ß2 agonist that binds to the receptors on the smooth muscle of airways. When it does this, it causes adenyl cyclase to make ATP in cAMP. This does three things. First, it inhibits inflammatory cells. It also causes hyperpolarization of the muscle cells, preventing contraction. Finally, it decreases calcium in the muscle cells and prevents the phosphorylation of myosin (a muscle fiber), both of which inhibit muscle contraction.

Epinephrine is most commonly used to treat anaphylaxis and asthma. It can be injected or inhaled. It acts on adrenergic receptors, and is also a hormone and neurotransmitter made by your body. The effects of it are the same as the effects of the sympathetic nervous system. So it will increase heart rate and contractility, increase respiratory rate, bronchodilate, inhibit insulin, and increase the breakdown of glycogen. On lists of its effects, you'll see that it vasodilates and vasoconstricts, but what it really does is decrease peripheral blood flow by constricting those vessels, and increase the diameter of coronary vessels.

Atropine is an antimuscarinic that is used to treat bradycardia (slow heart rate) and several types of poisoning. It does this by blocking muscarinic receptors, which can be activated by acetylcholine. This will decrease the slowing effect of the parasympathetic nervous system (inhibiting the inhibition and causing sympathetic effects), thereby increasing heart rate. In organophosphate poisonings (pesticide) and soman/sarin gas attacks, it acts the same way. In these poisonings, the enzyme that breaks down ACh (a neurotransmitter) is inhibited, and an accumulation of ACh occurs. Atropine is a competitive antagonist of ACh, meaning it locks into the same receptors but does nothing. It is usually used with another drug (pralidoxime), which can regenerate the enzyme that breaks down ACh. A fun fact about atropine is that it is found in the deadly nightshade (belladonna) plant, and is a poison itself (I mean everything can be a poison in the right amount but this is like a famous one).

Narcan is an opioid receptor antagonist, used for opioid overdoses. It comes as a nasal spray, as this allows it to bypass the blood-brain barrier and be absorbed really quickly. Its mechanism of action is that it blocks opioid receptors but doesn't do anything (conversely, opioids activate those receptors and modulate pain). One fun fact about this one is that someone should not need more than two doses of it. I've seen firefighters give someone three or four doses of Narcan and the person is not waking up. Don't do that. Something else is wrong and you should probably deal with it instead of wasting more Narcan.

If you need anything explained better, just send another ask, DM me, or comment on this post.

I hope I answered your ask well enough, and thanks again :)

[tzipporahs-well]

Theory for House of David:

I have watched the first 5 eps of the House of David now, and I have a theory.

The tinctures that Shaul is getting are making his mental state worse and possibly poisoning him.

Why?

Shaul HaMelech in the show is getting worse at a more rapid rate than Shaul in the Tanakh, whose mental decline took years. One episode he’s sleeping for 11 days and then the next ep he accidentally kills someone. This has descended to frequent hallucinations and possible paranoia. Out of universe, I know this is meant to move the story along. However, an in-story explanation provides great potential.

Intentional or Unintentional? 🧐

Intentional:

Motive: The crown and the priestesses of Ba’al do not have the best relationship

The priestess insists that more tincture will help and that she needs to be more unrestrained in her treatments.

Effects: Shaul is getting worse every episode, faster than in the Tanakh.

Unintentional

Medical knowledge and treatment sucked a lot.

There seemed to be a partial recovery a bit at one point.

What could it be?

We know that the drug is a tincture. Tinctures are plants or animal material dissolved in ethanol. However, we don’t know the route of administration. I have some candidates whose likelihood depends on the motive:

Opium: It was used for pain and inducing sleep in the late Bronze Age to early Iron Age. The Caananites also used opium in ritual specifically. In Egypt, it was used for priests and warriors and associated with the afterlife and the dead. In Israel, it was found in a burial site. Unfortunately, opiate use is infamous for tolerance, dependence, and withdrawal. Withdrawal can see overstimulation of the nervous system and create agitation and in some cases hallucinations (which we see in the show). Long-term, opiate use has been tied to increased risk of dementia.

Cannabis: a well known hallucinogen that was also found archaeologically in Israel and also associated with developing psychosis. This was also used for ritual purposes by the ancient Israelites. Cannabis has been used as a tincture.

Belladonna: the deadly nightshade is associated with hallucinations, confusion, and delirium with an overdose. Oral use increases the risk of psychiatric disorders. It can be administered as a tincture and also was used in Mycanean Greece. Belladonna has several toxic compounds in it including atropine, scopolamine, and hyoscyamine which have the same mechanisms.

Henbane: there are hypotheses that the Kohen Gadol decorated his hat with the henbane flower. Henbane was used by the ancient Roman’s and Greeks and often combined with other plants in “magic brews.” As a traditional medicine, it was used for all kinds of symptoms including nervous diseases, pain relief, and sleep. Hallucinations were common. Long-term henbane has been tied to dementia. It is however very poisonous if orally consumed.

Ergot: a fungus that serves as the source for LSD (a hallucinogen). There are two kinds of ergotism: psychosis, fever, muscle spasms, and mania while the other feature burning pain. The chronic effects are more so associated with the blood vessels rather than the brain.

Ethanol by itself: it could be the tincture has nothing active besides ethanol. However, ethanol by itself is a “dirty drug” that affects many different receptors (we still don’t know all the receptors it interacts with). Ethanol can induce a potentially fatal withdrawal with delirium tremendous (rapid confusion, seizures, hallucinations, and high body temperatures).

Lead: A heavy metal poison known to target the brain and the kidneys. The Iron Age saw increased incidents of lead poisoning. Imported silver and metal working was usually the cause but it could also be a case of intentional poisoning. Lead severely damages the brain leading to various disorders including mood changes (sound familiar?). Chronic exposure is linked to psychiatric disorders and neurodegeneration.

Mercury: cinnabar, a common Mercury ore often occurred with lead ores. Although mercury is well known for neurological effects, it’s the organic mercury that’s more potent at this. Something like cinnabar would need to be used at 1000 times that of methylmercury and it’s likely death would come from other causes.

Arsenic: “the king of poisons” or “inheritance powder.” Arsenic has been melted down to make arsenical bronze since the Bronze Age and very frequently used for murder until 1830s CE. The symptoms are nonspecific with chronic cases masquerading as intestinal diseases. However, it seems more associated with peripheral nerve problems rather than the brain in chronic dosing.

If I had to make a guess: opium, cannabis, belladonna, and henbane would be my guesses for an unintentional poisoning, and henbane or lead would be my guesses for an intentional poisoning.

[becky-resus]

Are you open to experimental resuscitation by any chance? Something like trying to bring you back even though you've been down for a long time and likely brain dead. I'd imagine you hooked up on a ventilator breathing for you and a LUCAS thumper mechanically pumping your chest. Injecting epi and atropine every so often. What do you think about that idea?

Really love this Idea trying everything to try to bring me back despite all the signs showing that I'm too far gone. Bring stapped under a Lucas and a ventilator mechanically forcing my body to not shut down.

Love the ideas

[endcant]

optimism from whatbeatsrock.com

(and a depressing look into my mind i guess)

epidemiology was declared illegal in the wake of a political disaster and misinformation surrounding a devastating pandemic does not beat epidemiologists tracing the source of the cholera to eliminate it

You can't declare a field of study illegal, that's not how science works. Epidemiologists are still tracing the source of that cholera, no matter what politicians say. 🦠😵🔍

score: 37

epidemiology was declared illegal in the wake of a political disaster and misinformation surrounding a devastating pandemic 😵 epidemiologists tracing the source of the cholera to eliminate it 🤜 cholera epidemic in the military's water supply 🤜 the military 🤜 the government is overthrown 🤜 a conservative pendulum-swing resulting in the enstatement of supreme court justices that enshrine private prisons' rights in the constitution 🤜 prison is abolished, so there is no prison time to avoid 🤜 the libertarians are arrested before dying and have to go to driving school to avoid prison time 🤜 the libertarians also disregard driving licensure laws and die in a bunch of car accidents because they never bothered to learn driving laws 🤜 libertarians disregard fishing licensure laws and therefore can't have their licenses revoked if they catch the wrong fish 🤜 the state makes it illegal to remove these fish from the wild 🤜 a massive trend of fish collectors overfishing these fishes, removing them from their natural habitat 🤜 worldwide proliferation of Siamese algae-eaters and Bristletooth tangs 🤜 an algal bloom that turns the carbon dioxide into oxygen, preventing the glacial melt that led to the end of the ice age 🤜 the extinction of the large prehistoric mammals it feeds on 🤜 Smilodon 🤜 moose that stomps on and destroys the medicine cabinet, shattering and spilling all of the vials 🤜 administration of atropine, diazepam, and oxime 🤜 the Novichok nerve agent 🤜 the FBI agent who is already tracking down this arsonist and sets up the fire supression as bait for an arrest 🤜 arsonist who stealthily destroys fire supression systems 🤜 fire supression system 🤜 explosion in the operating room 🤜 cyst removal by neurosurgeon 🤜 untreated Trichinellosis of the central nervous system 🤜 dishonest safety inspectors 🤜 good safety protocol 🤜 acid leak at a factory with bad safety protocol 🤜 skilled engineer 🤜 jammed mechanism 🤜 gun 🤜 bear 🤜 lumberjack 🤜 trees 🤜 carbon dioxide 🤜 rust 🤜 scissors 🤜 paper 🤜 rock

[sharkbeneaththelotus]

There's a reason for this Saddest Fate of Pharmacists:

Bitter taste buds evolved to detect Things That Do Stuff To Bodies.

So that we didn't die from eating too much tannins in mature leaves, or too much atropine in a nightshade berry. Poisons are bitter because our ancestors who had a detector for these poisons didnt Die of Eatting Pretty Berries.

Fast forward into the technological age and we discover hey! Atropine can accelerate a very slow heart rate! And a bunch of people survive digitalis poisoning by taking atropine(belladona extract). The tldr being; any medicine that can effect your bodies mechanisms can effect that mechanism to death, but doctors and pharmacists are very smart and knowledgeable the Correct Amount To Not Die! Love that for us.

But our bodies don't change their opinions on bitter chemicals just because we need medicine, so. We get this whole thing.

(another important thing to remember is that lots of pills look exactly like smarties. They are doped with Extremely Bitter Flavours to make sure little Timmy doesn't eat sixteen paracetamol and need his stomach pumped. U_U)

[mycalpharm]

Effect of Drugs on Isolated Frog Heart | MyCalPharm

Introduction

Pharmacological experimentation includes the examination of the “Effect of Drugs on Isolated Frog Heart,” an activity that sheds light on the various aspects of cardiac pharmacology. It helps to understand the action of different drugs on the cardiac physiology deeply. The experiment is a corner stone of pharmacology teaching during which students appreciate that drugs may cause changes in heart rate, contraction and conduction of impulses.

Simulation techniques, especially MyCALPharm, have proven to be valuable, allowing students and academics to undergo simulated intensive practice for those experiments. This article covers the details of pharmacological mechanisms and methods of the experiment as well as the results obtained from the study of the isolated frog heart.

Why Use an Isolated Frog Heart?

Frog hearts are frequently employed in pharmacological experiments as they straightforward to obtain, can be kept beating outside the body for extended durations, and have a mammalian similarity in their physiological responses. There are several reasons why the isolated frog heart is preferred:

Three-Chambered Heart: The heart of a frog has fourteen organs that are classified into two atria and one ventricle, and thus serves as a good representative model for the study of heart physiology.

Spontaneous Beating: The heart still beats after isolation because of its self-sustained pacemaker activity, facilitating direct observation of drug effects.

Pharmacological Sensitivity: The frog heart has discernible and quantifiable responses to various categories of drugs, which makes it suitable for experimental research.

Setup of Procedures and Experiments

To conduct the experiment, the frog’s heart is a part that remains functional in isolation and is perfused with Ringer’s solution to keep it alive. It generally includes the Following:

Dissection and Isolation: The frog gets a shot to the head (shock euthanasia) and the heart is ripped out and dissected manually, with care taken not to damage it.

Mounting a Device For Perfusion: The heart is placed on an apparatus that holds the heart while being perfused with oxygenated Ringer’s solution.

Recording Baseline Heart Activity: Before any pharmacological drug is administered, the patient’s heart’s default beating rate and contractility is recorded.

Administration of Drugs: Various diverse acts of pharmacological drugs are given and the changes or reactions noticed are recorded down.

Data Interpretation: The patient’s heart rhythm, contraction, and rate changes before and after administration of the drug are assessed to understand the drug’s action mechanism.

Different Classes through their Pharmacological Actions

1.Nullotropic Drugs

Drugs acting on muscarinic receptors in the heart has a stimulating effect, some of which include:

Acetylcholine (ACh): Decreases the heart rate through enhanced activity of the parasympathetic nervous system which causes hyper polarization induced bradycardia.

Pilocarpine: Acts as ACh and lowers heart rate, this drug acts like a muscarinic receptor agonist.

Atropine: An antagonist of the muscarinic type that blocks the actions of ACh and causes a rapid heart rate (tachycardia).

2. Adrenergic Drugs

Adrenergic drugs that function on beta-receptors modify the contraction rate and strength of the heart as follows:

Adrenaline (Epinephrine): Increases heart rate (positive chronotropic effect) and contractility (positive inotropic effect) through action on beta-1 receptors.

Isoprenaline: Nonselective beta-receptor agonist which produces marked tachycardia.

Propranolol: Competes with adrenergic stimulation causing bradycardia as a beta-blocker.

3. Calcium Next Attention Channel Modulators

Calcium is centrally important in cardiac contraction:

Verapamil: Reduces heart rate and contractility due to block of calcium entry to the cells.

Calcium Chloride: Increases cardiac contractility by providing more calcium for the myocardial contraction.

4. Cardiac Halleas Glycosides

Cardiac glycosides like Digoxin work by inhibiting sodium-potassium ATPase pump which increases intracellular calcium leading to increased constriction of the heart muscles Ditto increased contraction.

5. Local Anesthetics And Anti-Arrhythmics

Lidocaine: A sodium channel blocker that reduces excitability of the cardiac membranes decreasing arrhythmias by stabilizing them.

Quinidine: Inhibits ectopic pacemaker activity and decreases conduction.

6. The Cardiac Effects of Diuretics

Diuretics such as furosemide are commonly used for fluid balance, but they also affect cardiac function due to electrolyte derangement, specially potassium which is important in cardiac conduction.

Insights from Experimental Observations

A careful study of actionable drug effects informed that ‘study of action of drugs on isolated frog heart’ has good pharmacology information:

Autoregulation: It is very easy to illustrate the combined sympathetic and parasympathetic influence on the heart.

Graph Relations: Different levels of pharmacological agents have differing magnitudes of effect which displays simple principles of pharmacokinetics.

Receptor Actions: The capturing of the active or passive modification of specified heart receptors is possible.

Physiopathological Relations: The experiment obliges pupils to examine clinical pictures of arrhythmia, heart failure, and myocardial ischememia.

Advantages in Using MyCALPharm in Learning

MyCALPharm helps students learn pharmacology through accurate virtual simulation of experiments like the Effect of Drugs on Isolated Frog Heart creating other possibilities. For example:

No Violations: The approach does not breach humane standards of science as there is no usage of living animals.

Repeatability: Experiments are repeatable as many times as desired without interference from variability associated with biological specimens.

Deeper Understanding: Animated sequences offer a better conceptualization of physiological and pharmacological phenomena.

Safe and controlled Learning Environment: Students are able to learn about drug effects in a risk-free environment free from ethical issues and technical challenges.

Conclusion

Effect of Drugs on Isolated Frog Heart experiment is still an essential component of pharmacology research and education. Learning how various drugs affect heart function, students and scientists obtain fundamental knowledge of cardiovascular pharmacology. With the availability of sophisticated simulation tools such as MyCALPharm, learning is further facilitated, pharmacology teaching becomes more accessible, ethical, and efficient.

With such research, upcoming healthcare professionals are able to have a solid understanding of pharmacodynamics and pharmacokinetics, making for improved therapeutic use in the clinical environment. The incorporation of digital learning platforms such as MyCALPharm not only enhances learning but also supports contemporary advancements in biomedical sciences, setting the stage for pharmacology training in the future.

[market-insider]

Myopia and Presbyopia Treatment: Emerging Technologies and Innovations

Both myopia and presbyopia are common vision conditions that can impact daily activities. Myopia, commonly known as nearsightedness, is a refractive error of the eye that causes distant objects to appear blurry, while close objects can be seen clearly. It occurs when the eyeball is slightly longer than normal or when the cornea (the clear front surface of the eye) has excessive curvature. As a result, light entering the eye focuses in front of the retina instead of directly on it, leading to blurred distance vision. People with myopia may have difficulty seeing road signs, distant objects, or the blackboard in a classroom. Myopia can develop during childhood and typically stabilizes in early adulthood, but in some cases, it may progress. Presbyopia is an age-related condition characterized by the gradual loss of the eye's ability to focus on close objects. It occurs due to a natural aging process that affects the lens inside the eye. The lens gradually becomes less flexible, making it challenging to focus on nearby objects, such as reading material or a smartphone. Presbyopia typically becomes noticeable around the age of 40 and continues to progress until around the age of 60. People with presbyopia may experience eye strain, difficulty reading small print, or the need to hold reading material at arm's length to see it clearly. It is a normal age-related change in vision and affects virtually everyone to some extent.

Gain deeper insights on the market and receive your free copy with TOC now @: Myopia And Presbyopia Treatment Market Report

Recent developments in Myopia Treatment:

Orthokeratology (Ortho-K) involves the use of specially designed gas-permeable contact lenses that are worn overnight to reshape the cornea temporarily. This technique aims to reduce or control myopia progression, particularly in children. Ongoing research has been exploring the effectiveness and safety of Ortho-K for myopia management. Studies have shown that low-dose atropine eye drops can slow down the progression of myopia in children. This treatment involves using a diluted concentration of atropine, a medication that temporarily dilates the pupils and relaxes the eye's focusing mechanism. Research has been focused on determining the optimal dosage and long-term effects of this treatment.

Recent developments in Presbyopia Treatment:

Intraocular lenses are artificial lenses implanted during cataract surgery to replace the eye's natural lens. Advancements in the design of accommodative IOLs aim to provide improved near vision by allowing the lens to change its shape or position, mimicking the natural focusing ability of the eye. Ongoing research continues to refine the technology and assess its long-term outcomes. Corneal inlays are small devices implanted into the cornea to enhance near vision in individuals with presbyopia. These inlays alter the eye's focusing power to improve near vision while maintaining good distance vision. Different types of corneal inlays are being developed, and clinical studies are underway to evaluate their safety and effectiveness. Laser blended vision is a technique that uses LASIK or PRK to adjust the dominant eye for distance vision and the non-dominant eye for near vision, creating a balance for improved overall vision. This approach aims to provide a range of vision for both near and distance tasks, reducing the need for reading glasses.

[forensicfield]

Atropine Poisoning

Atropine is a prescription medication used to treat symptoms of low heart rate (bradycardia), to minimise salivation and bronchial secretions before to surgery, and as an antidote for cholinergic drug overdose or mushroom poisoning. Atropine can be used..

(more…)

[toxicologicalhimbo]

Aconite

"aconitum napellus"

Wolfsbane, Monkshood, Helmet Flower

C34H47NO11

LD50:

Orally: 1mg/kg

Intravenously: 0.1mg/kg

Intraperitioneally: 0.27kg/mg

Subcutaneously: 0.27mg/kg

Topically: No LD50, but numbness can occur

Mechanism

Aconite interacts with sodium-ion channels in the neurons. By binding to receptors in these channels, aconite forces them to remain open. This repolarizes the channel, resulting in a calcium influx that triggers the release of the neurotransmitter acetylcholine into the synaptic cleft. The acetylcholine binds to the next neuron's receptor, holding its sodium-ion channel open and continuing the reaction. These open channels suppress the transmission of action potentials, leading to paralysis.

Death occurs as a result of respiratory paralysis or cardiac arrest.

Symptoms

Neurological:

Parasthesia

Numbness or tingling sensations on skin (pins and needles sensation)

Numbness of face, mouth, and limbs

Muscle weakness

Cardiovascular

Hypotension

Low blood pressure

Palpitations

Sensible (palpable) abnormal heart rhythm

Chest pain

Bradycardia

Slow resting heart rate, under 60bpm

Sinus tachycardia

Elevated sinus rhythm and resting heart rate over 100bpm

Ventricular ectopic and other arrhythmias

Junctional rhythm

Abnormal heart rhythm from atrioventricular node in heart

Gastrointestinal

Nausea

Vomiting

Abdominal pain

Diarrhea

Other

Dizziness

Hyperventilation

Sweating

Difficulty breathing

Confusion

Headache

Treatment

Lidocaine

Blocks sodium-ion channels, preventing the aconite from holding them open, preventing or reducing paralysis

Atropine

Blocks acetylcholine receptors, hyperpolarizes cells to reduce effects and increase heartrate

Tetrodotoxin

Blocks passage of sodium ions, repolarizing channels and reducing or counteracting effects

Tannic acid/activated charcoal

Used if ingested orally, together, within an hour of the poisoning to absorb the toxin

Strong coffee/caffeine

Increases heartrate, supporting victim till medical assistance arrives

There is no antitoxin for aconite, all that can be done is artificial support to keep the patient alive till the toxin has been filtered out of the body.

Lingering Effects

None. Aconite does not cause any permanent damage or lasting effects

[kk095]

Candice's Acute PE

Candice was a 44 year old white woman, standing at 5'6 with a pleasantly plump build, shoulder-length brown hair, and brown eyes. Candice was always a history buff, so it’s no surprise that she worked as a history teacher at the local high school. Outside of work, she was married to her husband John for the past 12 years. The two of them never had kids, but Candice often joked that her students counted as her kids.

Candice didn’t have any significant medical history, but had been experiencing shortness of breath and heart palpitations on and off for approximately 3 weeks prior to the incident, and attributed her symptoms to the day to day stress of being a teacher.

Yesterday, Candice was brought to our emergency department after being found semi conscious and struggling to breathe in her classroom after school by the school’s janitor. The medics informed our emergency department that they set up 2 large bore IVs and hung a bag of normal saline, gave her nitro for her chest pain, and put her on an o2 mask with high flow oxygen. “Please… call John…” she said weakly to the medics while they prepped her for transport. The medics told her that the ER staff would get ahold of her husband, but that didn’t reassure her at all. “call him… I have to see him before I die!” she replied in a weak, wobbly voice. The medics told her she wasn’t going to die and that she was in good hands, but Candice had an impending sense of doom.

During the ride over to the hospital, Candice’s condition worsened. Her eyes were teary as she continued gasping for air. She began the cough up blood, which sprayed the inside of the o2 mask. She began coughing up larger amounts of blood, so the medics suctioned out her mouth while she continued to cough and hack away. Even though the medics cleared her airway of blood, she continued to frantically gasp for air. Her vital signs were also dropping rapidly despite the medics' attempts to stabilize her.

Suddenly, Candice’s cries and gasps stopped. She let out a calm exhale and her eyes opened wide, drifting off into unconsciousness. The heart monitors displayed pulseless electrical activity, so the medics had to start coding the 44 year old in the back of the ambulance. The medic in the back of the ambulance set up the Lucas thumper so they’d be able to multitask more easily.

Once the Lucas thumper was wet up, it began delivering perfect, mechanical chest compressions. Candice’s chest caved in, and her large, natural breasts jiggled in sync with the machine’s motions. The medic then injected doses of epinephrine and atropine into the teacher’s IV in an attempt to obtain a shockable rhythm. The next step was to intubate her. A 7.0 ET tube was carefully navigated into her airway during ongoing compressions. This was a bit of a moving target for the paramedic, but they were able to successfully place the breathing tube and secure it with a blue tube holder. Once the ambu bag was attached, the medic started bagging her while the Lucas thumper did its work.

The first handful of cycles proved ineffective since Candice remained in PEA, so the next round of drugs were pushed intravenously at the 3 minute mark of the code. After just one more cycle of ambu bagging and Lucas compressions, Candice converted to v-fib. The medic gelled the defibrillator paddles and began charging them. Once the paddles were ready, the Lucas was paused and the paddles were placed up against the patient’s bare chest, and a 250j shock was delivered. Candice’s body jolted violently in response to the shock, but failed to produce a change. The medic resumed the Lucas compressions while they gelled and recharged the defibs to 300j. Moments later he paddles were ready and the next shock was delivered. Candice’s back arched, thrusting her chest into the air while her eyes stared lifelessly above. Once again, this shock failed to convert her out of v-fib, so a 360j shock was delivered shortly after. This shock caused Candice’s feet to leap up above the gurney before slamming back down a second later, showing off the thick, soft wrinkles throughout the soles of her size 9 feet. The third shock sent the cute teacher back into PEA, so the medic resumed the Lucas thumper.

Candice arrived at the emergency department a few minutes later and was still in PEA despite Lucas thumper compressions and another dose of epinephrine and atropine, having a total down time of 6 minutes at that point.

After the medics informed the ER team of the situation, they removed the Lucas thumper and let the ER staff take over. A nurse began deep, harsh chest compressions on the patient, causing her head to loll and her belly to bounce outwards from the residual force of each individual compression.

With CPR ongoing, the attending physician ordered a battery of blood tests: a CBC, BMP, tox screen, cardiac enzyme test, and a d-dimer. After all the blood was drawn and sent off to the lab for stat testing, a chest x ray was performed. The x ray showed a 2.8cm right atrial dilation, but no other noteworthy findings. Because of the right atrial dilation, the ER attending ordered an echocardiogram. The echo further confirmed the right atrial dilation, but didn’t show evidence of any other conditions on the short list of diagnoses such as: major STEMI, thoracic aorta or SVC aneurysm, or structural heart defects. The attending thought this was either a PE or a bleed in the lungs from undiagnosed pulmonary artery hypertension. The treatments for these 2 conditions are very different from one another and the wrong treatment could exacerbate things, so the ER team’s goal was to obtain ROSC and send her off to radiology for a chest CT angiogram.

Around the 10 minute mark of the code, Candice converted back to v-fib. The orange defib pads were stuck onto her bare chest and the electric whirring of the defibs being charged could be heard amongst the organized chaos in the room. When the paddles were ready to go, they were pressed up against Candice’s chest and a 300j shock was delivered. Her body flopped quickly on the table as the jolt of electricity coursed through her lifeless body. V-fib remained on the monitors, so a cycle of chest compressions were delivered while the paddles were readied for the next shock.

A short while later, the paddles were recharged and a 360j shock was promptly delivered. Candice’s arms and legs bounced around in response to the shock. This shock sent the 44 year old history teacher back into PEA, so CPR was resumed.

The nurses pumped away at Candice’s chest cover the coming minutes to no avail. Her ET tube began to fill up with blood, so the ambu bag was detached and the tube was suctioned out in order to obtain a clear airway. The suction tube made a slurping sound while it withdrew both fresh blood and clotted blood from the patient’s airway. After a few quick rounds of suction, the airway was restored and the ambu bag was reattached and the code continued.

Candice continued to receive deep, violent chest compressions. Her flabby torso jiggled around, and her left arm hung off the side of the table, bouncing slightly, in sync with the CPR that was being performed. The next dose of meds were injected into her IV, but the ER team began to grow less and less optimistic as more time went on.

It took another 5 and a half minutes, but Candice converted back to v-fib at the 17 minute mark of the code. Once again, the paddles were charged and pressed up against the history teacher’s bare chest. Once everyone backed away, 300 joules of electricity were sent back into Candice’s dying body. The shock forced the 44 year old’s limp body to twitch abruptly in response to the jolt of electricity. Once again, Candice wasn’t able to be shocked out of v-fib, so the team recharged the paddles and hit her again at 360. Her toes scrunched, wrinkling the soles of her feet; post shock, her toes relaxed from their clenched position. Another unsuccessful shock was delivered before Candice once again converted back to PEA.

One of the nurses resumed CPR on Candice. They could feel her cold, clammy skin through their gloved hands as they pumped the cute history teacher’s chest repeatedly. Candice’s chest was red and bruised from several broken ribs and the constant, forceful pressing of her sternum. Her eyes remained wide open, with a blank, lifeless stare up above while her head bobbed around slightly from the compressions.

Candice was given another dose of meds at the 19 minute mark of the code, and converted to v-fib 2 minutes later. The ER team shocked Candice 3 more times, and coded her for another 5 minutes to no avail. Despite the ER staff’s best efforts, time of death was called on Candice at 15:53 while she was still in v-fib after a 26 minute code.

The ambu bag was detached and the chirping heart monitors were turned off. The nurses shut Candice’s eyes for the final time and began plucking the EKG electrodes off her bare, battered chest. The orange defib pads were peeled off and her body was covered up with a sheet, only leaving her feet exposed. A toe tag was placed on the big toe of her left foot before she was sent up to the hospital morgue.

The autopsy revealed a series of small blood clots in the smaller blood vessels of the lungs, explaining Candice’s 3 week history of symptoms. However, a large blood clot was found lodged in the right pulmonary artery, explaining her right sided heart issues and sudden deterioration. If Candice sought treatment earlier, it’s very likely she would have survived, making the case even more sad for all of those involved.

[penaltybox14]

So on Tuesday, we had a patient who’d come to the hospital (a Boston hospital, but smaller and less equipped than its larger cousins) with a complaint of dizziness for the past two weeks.  It turned out that he had a heart rate of less than 40 (average for an adult human is 60 - 100 beats per minute), due to something called a heart block (3rd degree).  Heart blocks, which come in multiple degrees of severity, are basically a disruption of the electrical current through the heart.  They occur due to damage to the heart muscle, often from a heart attack.  While the patient had no heart attack on his record, it’s possible to have a heart attack, recover, and not know it.  But anyway, the solution to this electrical problem is more electricity.  People with heart blocks get pacemakers, which make sure the heart beats at a certain set rate by replacing the heart’s internal electrical signals.  Pacemakers and internal defibrillators are very cool, and keep people from dying. 

But Badger, what do you do when people are bradycardic but don’t have a pacemaker yet?  Well, in people where it’s a chemical problem, we can give them a medication called atropine (which was first derived from the belladonna plant!), but when it’s a mechanical problem, they can be transcutaneously, or externally, paced.  Generally, this is reserved for when the patient is showing signs of poor perfusion - altered mental status, hypotension, etc - because it has its own potential issues including being, um, painful.  So I’m told. 

External pacing is done by placing debrillator pads, connected to a cardiac monitor, on the patient, setting the desired rate (usually 70bpm), setting the milliamps, and increasing the electrical dosing until mechanical capture - the patient’s heart is beating at a regular rate that adequately perfuses the body’s tissues.  Our patient, being alert, oriented, and not hypotensive, was sort of a borderline candidate for pacing.  I did consider it, and I set him up on pads in case I needed to do it in the ten minutes it would take to get to the bigger hospital with the cath lab and the cardiac surgeons.  This is absolutely something a paramedic should do in this case, because you don’t want to waste precious seconds getting out the pads if your patient’s status goes pear-shaped.

All of this is background to my main complaint: there are multiple different manufacturers of AEDs and cardiac monitors/defibrillators, as well as multiple different models of each, and the brands are not compatible.  That is, I can’t plug my Zoll pads into a Phillips monitor/defibrillator, or vice versa, and neither will be compatible with a LifePak.  There are adapters that exist, but they are aftermarket and/or expensive - particularly expensive if you have to equip your entire medic fleet or at least your IFT trucks with adapters for each machine. 

(side note: I’m also writing this post to avoid my schoolwork)

Is this a big problem?  Yes and no.  Is your patient generally stable enough on a transfer that it won’t be a huge deal to take a few seconds to swap the pads?  Well, yes.  (However, as you can imagine, whipping off two hand-sized, ultra-adhesive pads from someone’s torso is really uncomfortable for the patient, think ripping off two GIGANTIC BANDAIDS).  However, as stable as my man here is, there is, as noted, the high, high potential for a patient like this to decline abruptly.  In fact, as we were wheeling him into the exam room at the real hospital, he turned to me, very distressed all of a sudden, and said “I’m having trouble breathing.”  I may or may not have spoken VERY abruptly to the doctor (who I thought was a nurse because how many of you have ever seen a doctor in a hospital? no? yes? really?) because hey this is a change in patient status and A POSSIBLE BAD SIGN FOLKS.  I wanted the hospital’s pads on him like *now*, right now, because guess what?  MY PADS ARE NOT COMPATIBLE.  I can’t just wheel the code cart in and plug and play my heart block patient.  It’s just ridiculous.  Why can’t they be compatible?  Corporate nonsense.

[orangetail-works]

A Phoenix and a Raven: Mission Impossible

A/N: The prompt for this one is a little long, but I think it would be impossibly cute.  PROMPT: Person A was sent to kill Person B but they got hurt and now Person B is naively nursing Person A back to health and calling them cute pet names and Person A just cannot do this.   It turned out to be its own monster, let me tell you.  A lot longer than I thought it would be and so different than what I originally planned for plot.  Once I start typing, all plans were out the door.  Happy reading!

Chapter: Mission Impossible

“Well, it looks like everything is in order.  You will have a protection order if you so choose and an unmarked vehicle parked on your block,” the officer read off from a page and stood up to stretch out his legs. His deep voice echoed off the walls of the dank and blank walls of the interrogation room walls around them making it seem more like a cave or dungeon, “Do you have any questions?”

A younger man sat behind the table, his hands in his lap as he scanned his eyes around the room and then to the officer in front of him, “Is all this really all that necessary?  He doesn't even know who I am.”

“You can't think that he doesn't,” the officer warned and sat down across from him again, “You are the only witness that we have against Stefan Barnes.”

“I'm not even sure if what you're saying is what I actually saw,” he argued and leaned on the table.  He folded his hands over one another on the steel surface, “You all are making speculations at this point.”

The officer opened the statement that he just signed, “You saw Mr. Barnes walk into the coffee house and joined Henry Perce at the table.  After they talked over a few items- including the addition of Stefan to the man's will as successor- Henry was distracted.  You noticed Stefan add something to his cup.  A sip later and the man is dead.  Yes, you don't know what was in that addition, but you can see where we would connect the dots.”

“It could have been sugar and the poor guy choked on the bagel he was eating!”

“And the coroner just happened to find a fatal dose of Atropine in the system?”

The guy leaned back in his chair a little exasperated, “Why would Barnes single me out?”

“How many other patrons were in that coffee shop at the time?”

“We have been over this.  Other than them, it was me and two men at the front.”

“Those other two men are already dead.  Car wreck, highly suspicious,” the officer shook his head, “Mr. Barnes has connections to the darker parts of our city.”

“Like?”

“Like assassins.”

“Assassins?” a moment passed as he waited for the punchline, but it never came about, “I'm starting not to take this seriously.  If you think that this man is truly guilty and you need my help, I will.  I will testify that I was in the coffee shop, enjoying my morning when a gentleman died and I saw something go into his cup before hand.  But I don't think that statement is worth my life.  I doubt they would think that either.  Any lawyer worth their merit could argue what went into that cup.”

“Or just rid of the problem to begin with,” the officer argued back, but then shook his head, “Don't come back to haunt us when you get taken out by someone like Black Feather, Phoenix or the Green Curse.”

“I am an insignificant man in the larger realm of things,” he pushed up from the chair, “Can I go now?”

“You are free to go and live your life.  However short you make it, Mr. Fitheach.”

“Diaval, please,” he threw back and then walked out the door.

Diaval left the police station and shook his head at the slight audacity of the officers.  How a morning coffee and something to nibble on can lead to a murder investigation he had no idea.  Now, all he wanted was something to eat and head home.

As he reached his car in the parking lot, he noticed a small puddle of liquid from under one of the back tires.  He leaned down and took a peek to see liquid not only falling from the one tire, but from the other back tire as well.  He hummed to himself and leaned back.

“That doesn't look good, 'ol girl,” he patted the trunk of his car from the bumper.

He frowned at his reflection in the chrome and noticed another form behind him.  He looked over his shoulder and his chin nearly dropped to the ground. Diaval looked up to see one of the most stunning women he had ever met.  Her eyes nearly glowed green with hazel gold, sculpted cheek bones and her brunette hair straight and shining under the sun.  A small shoulder bag hung at her side.  She wore a flowing dress that still was able to show off her slim figure and a short dark jacket and covered her top.  Her hands were behind her back as she looked over him.  

“Is everything all right?” she only lifted her brow as she looked him over.

He quickly scrambled to his feet and dusted himself off in front of her, unsure of how to continue without making himself out being a complete fool. His mouth opened and closed in an attempt to say something. Anything.

“With your car?” she asked as if she needed to explain her inquiry further.

“Oh!” Diaval turned back to his car and then back to her, “She's a bit of an older vehicle.  Been falling apart for years.  Need to get myself another new model, you know?”

“Is uh... she safe to drive?”

“Probably not,” Diaval shrugged and bumped the tire with his toe, “I am no mechanic, but she seems to be leaking some kind of fluid.  No problem, I will catch a cab more than likely.”

At that point his stomach began to growl and he looked mortified as he looked from his stomach to the woman.  He scratched at the back of his head in embarrassment, “Sorry, I'm a bit peckish.  Been in a meeting all morning.”

“If you head down 5th street, there is a lovely little bistro-” she offered and began to point before she stopped and took his hand, “Come with me.”

“W-wh-hat?” he stammered, but let her lead him irregardless.

They found a booth with no problem and she sat down across from him.  She peered over at him, her eyes narrowed as she looked him over. He was nothing special as far as he knew.  Dark hair, darker eyes and a penchant for dark clothes as well.  He desperately hoped that she didn't think he was into the darker side of life.  He actually enjoyed the brighter side quite a bit.

“You are a bit of a quiet one, aren't you?” she asked and took off the short jacket. It slid off her shoulders and fell beside her in the booth seat.  She grabbed the menu and began to peruse the selection in practiced familiarity.

“Just wait until you get to know me,” Diaval shook himself out of a quiet stupor, “Then it's a bit of a difference, I am afraid.”

“Afraid?  You talk too much?” she asked with a slight frown though she kept her eyes on the menu.

“I wouldn't say that either,” he shrugged and tried to distract himself with the menu as well, “I don't slip secrets or anything of the sort, but once I am familiar with you, I start to spout gibberish or facts about things that I find interesting.  My interests aren't always everyone's cup of tea.”

There was a slight pause and he flicked his eyes up to find her staring at him again as if waiting for something.

“Such as?” she prompted.

“Oh, well,” he looked out the window for a moment, his brain scrambling to remember his own interests.  Sitting not to far away from them on a small tree were two ravens and he smiled, “Ravens.”

“Ravens?” she tilted her head and another brow lift.

“Yes, did you know they have to be the most intelligent of birds?  Right up there with chimps and dolphins as far as brains in the animal kingdom.”

“You don't say,” she said in a aloof tone, but he saw the slight smirk in the corner of her lips.

The waiter came back to the table, “Are you ready?”

“We will both have the lobster bisque with a basket of french bread to share with extra sharp cheddar,” she handed her and his menu to the waiter without another word.  The waiter bowed and walked to the kitchen.

“How did you know I wanted the bisque?” he tilted his head.

“I'm a very observant individual.  I saw your eyes drift to it more than once,” she nodded and looked at him again.  She leaned forward on the table, her perfect skin almost luminescent in the bistro's dim lights, “Tell me something else.”

“About ravens? Sure, they are very adaptable.  Able to trick most of their predators to actually hunt for them.  They can mimic a wolf's howl so that a pack will take down an elk or open up a fresh kill and the raven will feast on what is left. Not only that, they usually know if they are being watched and will try to trick other birds on where their hoard is hidden.  Clever things.  They are also very empathetic.  Care very fondly for one another.”

“You are passionate about them.”

“They're on my family crest.  I started young,” he scratched the back of his head a little in embarrassment.

“Do you see some raven qualities in yourself?” she asked as the bread and cheddar was placed between them.  She immediately took a slice of the bread and a piece of cheese to her plate to nibble on.

“Adaptability, I would say so,” he nodded and then shrugged, “I don't know about intelligence as I keep putting myself in bad situations.”

“Is that why you were in the police station?” she asked.

“More of wrong place, wrong time, but nothing on the criminal spectrum, I assure you.”

She hummed to herself and took a bite of the french bread and the cheese.  She shifted in her seat and then her jacket fell to the floor.  She muttered something as she put a hand to her mouth so she wouldn't spit out her bite.

“I got it,” Diaval assured her and picked up the jacket from the floor.  He handed it back to her and she nodded her thanks after she finally swallowed.  She put the jacket on the other side of her.

“The bread and cheese is so good here,” she mentioned and looked up at the waiter as he set down their bisque, “Thank you.”

“I am more of meat eater,” Diaval mentioned and picked up his spoon to dig in to his bisque, “Even if it is shellfish.”

She looked a little disappointed, but continued with her meal.

The rest of the meal was spent talking over his other interests- food critiquing mostly.  Then it turned to her quite quickly as he wanted to know more about her.

Hesitantly at first, she told him very vague things of her childhood and her family.  Her parents had been killed on the same day, leaving her distant relatives to care for her.  The harsher life that she fell into after being used to more grand things when her parents were still alive.  She even went into the silly crush in her youth that turned into a dead end.   After minutes slipped by and an hour almost passed them by, she relaxed and more of herself opened to the stranger.  Her standoffish nature melted away with the minutes and she even found herself smiling at something that he said, but then the smile would turn sad and she would build another wall up behind her eyes.  

“I still manage to find myself still at his beck and call,” she sighed heavily and scooped at the last of her bisque with the last bit of her first slice of bread.  She popped it into her mouth and then sighed, “He calls for favors and I fulfill them.  Even now, when he has moved on and married and has a child of his own.”

“You still love him?” Diaval asked and poked his spoon in her direction.

“I don't even know anymore,” she answered truthfully and looked at his bowl, “Are you going to finish?”

“I am finished,” he pouted with a slight chuckle and looked at his bowl which held smeared remnants of his bisque.

“No, you are not,” she frowned and reached over to pick up another piece of french bread.  She put it in front of his face to show him, then mopped the bottom of her bowl with the bread until it was clean and took the bite that had the bisque.  She nodded then as if to show him that was the way it was done.

“If you say so,” he huffed and frowned at his bowl, “I think that I'm all full.  You know, we've been here talking this whole time and I don't even know your name or why you'd even want to sit down with me.”

There was a long silence and he looked up to find her eyes dilated and her breath shallow.  She blinked slowly a couple of times before she frowned a looked at the table confused.

“Are you okay?”

“I- I- so stupid,” she gasped between breaths and dug into her purse.  She brought out a vile and drank some of the substance inside.  She took deep breaths after and continued to blink slowly.

“You need help, I'll call-”

“No!”she yelled tough it was quite slurred and put her hand over his, “No ambulance, no police... please.  I'll be fine- had medicine.”

“Are you having a reaction to the food?” he asked and put his other hand over hers.

“You could say that,” she smirked and began to waiver in her seat.

“I need to get you out of here,” he whispered to her and she only bobbed her head.

“Is there a problem, sir?”

“She's having a bad reaction to the food.  I don't know why,” he said and walked around the booth to grab her jacket and threw it over her shoulders, “I will pay in a moment, but we have to leave now.”

“We did not know that she was allergic to shellfish-”

“It wasn't the shellfish,” Diaval muttered, “She got sick after eating more of that bread.”

“Take your wife home, sir.  We will take care of the check,” a manager came up from behind the waiter, “She doesn't look well to stay.”

“Thank you,” Diaval didn't bother in correcting his assumption and picked her off her seat.  He pulled her arm over his neck as she wobbled as soon as she stood.  He held her tight around her waist and pulled her against him so she wouldn't fall to the floor.  They made their way out to the curb and waved down a taxi.  He settled her in the cab and then sat next to her, “Where are we going?”

“Going?  Are we on a trip?” she asked with a hand to her chest.

“One of us is,” Diaval noted and looked to the cab driver, “Home it is.”

He gave the cab driver his address and they were off.

Once they got to the apartment building Diaval helped her out of the cab, to the elevator and all the way in to his studio apartment.  He laid her gently on the bed and headed to the sink.  He dampened a washcloth with cool water and came back over to her.  He patted her forehead with the cloth and noticed that her breathing had finally evened out.

“Are you still with me?” he asked and brushed the washcloth carefully over her forehead, “You gave me quite a scare back there.”

“Barely,” she huffed and her eyes fluttered open, “I'll be okay.  Took medicine. Do not call-”

“I know, no doctors, no cops,” he smirked, “Just like me to find a stunning woman with a possible sketchy past.  Don't even know your name.  This is what I mean about the lack of intelligence.”

She gave a soft smile back at him and put a gentle hand at his cheek, “Such a empathetic raven, you are.”

“That's me,” he nodded, “Are you okay to sleep?”

“Sleep would be good,” she nodded and turned her head into the pillow.

“Well, we may be here for a little while,” he hummed and went to re-wet the cloth.

Diaval didn't leave her side for more than a few moments at a time over the next few hours.  She would talk in her sleep of ripped wings and dangerous places, but nothing that made sense.  He trusted that she knew what she had talked about with the medication and he hoped to God that she would wake up good as new.  Evening time came about and he cooked basic bacon and eggs at his stove as that was all he had in the fridge.  He was not used to company and he definitely did not see her coming into his life.

“Are you cooking bacon at this hour?”

He quickly turned to the voice from the side of the room.  She sat up in the bed, a hand to her head as she blinked and tried to make sense of her surroundings.

“... and eggs,” he added with a nod.  He took the pan off the fire and walked over to her, “Do  you need anything?  You've been out for the past five or six hours now.”

“Water,” she said and grimaced as she held her head.

“As my mistress commands,” he nodded and went to the fridge to pull out a bottled water.  He brought it back to her and sat at the end of the bed.

“Mistress?” she asked as she took a sip.

“I still don't know your name,” he offered back and shrugged his shoulders, “With you getting as sick as you did, I thought that you had the right to order me about if you needed.  So, what else does my mistress ask of me?”

“I have been out cold for the last five or six hours and the worst you have done is come up with a nickname for me?” she asked a little shocked.

“Another thing you need to know of ravens,” he stood up and pulled at the front of his shirt, “We are gentlemen through and through.”

“And here I thought that you could have been a dragon,” she added on.

“I bet if you give me the right motivation,” he shrugged and turned to the stove, “I'll get you a plate.”

She watched after him and looked over the side of the bed where her purse laid on the floor.  It was still partially open, but she found all of her items there.  Everything that she had was still in the same pockets, the same lay out that she had meticulously put them in.  He didn't even look for a wallet- a phone.  He just trusted her to know and do what she asked of him.

“You trusted me...” she whispered.  Then to the side of her bag was a bowl of water and a few drying washcloths on the rim.  He had cared for her during the time she was out.  She knew so many people who would have left her on the curb, but he took a stranger into his home and helped her in whatever way he could, “You tried to help me.”

“You seemed to know what you were doing with that medication, but you were getting warm and weren't sweating.  I hoped that you weren't running a fever. Whatever you had a reaction to from the bread was bad,” he said as he came back over to her and handed her the plate with a fork, “Hope you can eat something now, Mistress.”

“I don't need you to call me Mistress,” she narrowed her eyes playfully at him.

“Well, then I will need to call you something,” he smirked and went to grab his own plate.  He sat down at the end of the bed again, “You can call me Diaval.”

She looked him over and shook her head before she let out a single syllable, “Mal.”

“Okay, Mal,” he smiled brightly and then began to eat.

She took a long look at him one more time before she began to eat.

A few hours passed since she first woke up and during that time they found more to talk about between his food critiquing and her mysterious food allergy to pass the time.  He also showed her his collection of polished gem stones as he was always drawn to shiny things and strange little nick-knacks.  She told him some of the gemstones were used in a variety of ways and he was enamored with her knowledge.

She looked at his bookcase where there was a picture of him and a little girl with golden curls, “You have a daughter?”

“Oh, no,” Diaval smirked as he caught sight of the picture she was looking at, “That's Rory.  She's my little sister.”

“She doesn't look like you.  I don't see the family resemblance.”

“Not blood related,” Diaval walked up to her and pointed to the shirts that they were wearing in the picture, “Part of the big brother program. Knew her since she was just a little thing.  Her parents aren't around much.  She usually stays with her aunts for the most part. Her mother's busy with her own father and his business and I never met Rory's father.  She doesn't talk about him much.”

“Hm,” Mal hummed and drew a finger down the girl's hair, “Pretty little thing.”

“Turning sixteen in a few months.  Throwing her a party since her father won't.”

“You sound more like a father than a brother,” she folded her arms over her chest.

“Sometimes feels like it,too.  I call her my little fledgling,” he took a pause and looked at Mal, “She would get a kick out of you.”

“Would she?”

“Always likes a puzzle, just like me,” he laughed at her expression.

She paused for a moment as if in deep thought, “You are a good man, Diaval.”

“I don't know about that, I'm just trying to do my best with the cards I'm dealt,” he felt his cheeks heat for a moment and walked toward the washroom to make sure he didn't embarrass himself.

“Diaval?”

“Yes, Mistress?” he asked as he reached the door.

She frowned again at the nickname, “Thank you again for your hospitality... and the meal.”

“Anytime,” he hesitantly turned back at to her and leaned on the door frame, “Would be quite happy to do it again, in fact.”

“We shall see, you silly bird,” she teased him.

He excused himself to the restroom, but when he came back out she was gone and there was a small handwritten 'Thanks again' on his bed.

“We shall see,” he whispered and let out a sigh before actually getting some sleep.

Over the course of the next few days, Diaval was able to pick up his car from the police lot.  He found out that it was his brake lines that were leaking from behind his tires.  Definitely not a good sign.  He was happy that he noticed the leak, otherwise he would have been devastated if something happened to Mal if he had tried to drive them to his apartment in his car after her food allergy episode.  The cops were even more paranoid- as was the usual.

He walked down the sidewalk on his way to the market for some essentials when he turned the corner and ran right into someone.  They both spun for a moment and he landed with his back against the brick wall and the other person right in front of him.  He looked down and a smile bloomed on his face.

“Mistress!”

“Hello, silly bird,” she greeted and dusted herself off as she took a step back from him.

“I'm not just a bird, a raven,” he corrected and pushed himself from the wall.

She turned to one side and pulled him with her as he heard something hit the wall where he just was, “What are you doing, running around without your car?”

“She's falling apart,” he shrugged.  He heard something hit the ground behind him and he turned his head to look, “Ready for a new one, I think.”

“You could always walk and taxi,” she shifted again and pulled him with her with a grip at his sleeve.

“I guess- what are you doing?” he asked with a chuckle.

“Thinking,” she narrowed her eyes, “Are you free tonight?”

“I- I... uhm, yeah,” he muttered out.

“Good, come with me,” she looped her arm through his and began to walk down the opposite corner of the building.

“Where are you leading me this time?” he asked, but was happy to be led.

“Dancing,” she smiled up at him as she led him to a little hole in the wall dance bar, “It's as close to flying as you can get around here.”

The next few weeks continued on much like that day.  To or from work, Diaval would bump into Mal or vice versa and they spent the rest of the day or evening together.  They would have dinner- taking great care with any gluten- or would enjoy one another's company in an outing.  He even introduced her to Rory on one occasion.  She was a bit uncomfortable with the teenager at first, but warmed up to her in mere moments. Rory had a way to do that with people.  When she had left to walk to the town car her mother sent for her she had hugged Mal goodbye.  It shocked the usual stoic woman who lightly hugged her back.

“She is quite delightful,” Mal said as they waved down at Rory from his window, “You've done a wonderful job with her.”

“She's a good kid all her own.  Didn't need me,” he waved her compliment away and then turned from the window.  He walked to the television and held up a couple of disks, “What's it to be tonight?  Horror or slap stick?”

“You know I enjoy a good blood bath,” she smiled warmly over her shoulder.  He went back to the player to get the disk ready while she turned back to the window.  She looked up at the top of the next building over and frowned.

“Are you ready?” he asked from the couch.

“Yes, just going to close the blinds,” she said quietly and she moved to do just that.

The court hearing finally came and Diaval was asked to come to play witness.  He dressed his best as it was still a court room and rolled his neck. He really disliked court.  Even if he was just to be a witness.

“Are you sure you should do this?” Mal asked from the end of the bed as he fiddled with his tie, “The police are constantly at your block and haven't lost sight of you in weeks.  What if they really have something to this whole assassination attempt?”

“If there was a hit on me, I would have noticed it by now,” he rolled his eyes and walked over to her.  He knelt down in front of her to look her directly in the eyes, “And I wouldn't have let you anywhere near me if it meant that my dear mistress was in danger.”

“I know you wouldn't,” she pinched his chin playfully and looked at the mess of a tie he had on, “Let me see this.”

He sat still as she fixed his tie and pulled on it to make it secure.  He watched her face as she concentrated on the knot.  Her straight hair fell flawlessly over her shoulders and her lips pressed and puckered as she worried over the tie in her hands.  Her beautiful eyes swept from one side of his collar to the other and then to his face when she had finished.  For a moment he couldn't catch his breath.

He coughed into his hand to clear his throat, “How do I look?”

“All preened and ready to go,” she smiled and carded a hand through his hair, “Handsome raven as ever.”

“You coming with?”

“Of course I am,” she smirked and followed him to the door, “Need to make sure you stay in one piece.”

“And just what are you going to do to an assassin should one come after me?” he asked as he opened the door for her.

“You'd be surprised.”

After the hearing they stood outside the courtroom and heard that the case was going to trial.  In part thanks to his testimony and there were also more factors and evidence to consider.

Diaval nodded to her and then toward the elevator.  He laughed to himself as they waited, “Well, if they wanted me dead before, it's going to be worse now.”

“Stop talking like that,” she hit his chest with the back of her hand.

“Should I take them up on the safe house?” he joked, earning yet another hit to his chest.

“Mister Fitheach!” a voice called from down the hall.

Both Mal and he turned to see Stefan and his lawyer walk toward them.  Mal stood in front of Diaval as they approached.  Diaval put his hand on her arm and took the step in front of her in response.

“Don't think it's a good move to talk to a witness outside of court, Mister Barnes,” Diaval said and stuck his hands in his pockets, “I don't have anything for you.”

“All my client wants is the truth,” the attorney summarized.

“Then he needs to remember what he put in that cup of coffee.  I told them what I saw. I didn't say it was poison and I didn't say it was creamer.  The jury can think for themselves on the contents.”

“You little piece of crap,” Stefan took a step toward him.

Mal was instantly in front of Diaval and took a long look at Stefan in the eyes.

“Mally,” Stefan breathed out and looked from her to Diaval and then back again, “Not as strong as I thought you were.”

“Stronger than you ever dared to hope,” she growled back at him.

“I would sleep with one eye open, Fitheach,” Stefan said as he still stared at Mal, “She's not who you think she is.”

“Come on, Stefan,” his attorney pulled at his client's arm to the elevator.

As soon as the elevator door closed Mal let out a breath.

“I didn't know you knew him.”

“I thought that I did,” she muttered and looked at Diaval who just looked confused and a little hurt.  She took another deep breath in, “I need to tell you something.”

“Something that is better in private, I think,” he nodded and pushed her toward the other elevator that arrived.

Once they made it to his apartment, he threw off his jacket and pulled off his tie.  He sat on his small couch and looked up at her, “So?”

Mal shuffled on her feet and opened her mouth a few times to start, but couldn't get very far past one word.  He ran a hand through his hair and shook his head as she struggled with words.  He got back off his couch and went to the cupboard for a glass and something harder to drink than water.

“This is harder for me than you think it should be,” she finally said after he took a shot.

“He's the childhood crush, I get it,” Diaval nodded and turned to lean back against his stove, his arms crossed over his chest, “Did he send you to- what?  Provoke me?  Threaten me?  Distract me?”

“No, he... he,” she muttered and let out a muffled scream from between her teeth in frustration, “He did much worse.”

“How's that?” Diaval tilted his head to the side in wonder and then shook his head, “How could it be any worse than throwing your ex at a man even though she still had feelings for you?  What kind of man would do that to someone who clearly cares for him?”

Mal's lips trembled a little and she looked away for a moment to pace.

“Did he tell you to keep seeing me?  Running into me?”

“No!” she fumed, her temper now beginning to show.

“Then why do it?!”

“To keep you safe!” she screamed and threw her bag across the room and onto his bed.

“Safe?  From what?”

“From others like me,” her shoulders dropped and she stared at him with a gloss over her eyes, “Others that would take my place and try to kill you.”

“Kill me?” he narrowed his eyes at her and opened his mouth to say something else, until he ran right at her.  He caught her around the middle and they both dropped to the floor just a moment before the vase behind her shattered.  He stayed over her for a moment before he looked over at his windows, now wide open instead of closed and locked like before. He then looked up at the wall and noticed the red dot that had been over Mal's chest.  He looked down at her and raised a single finger, “We are not done with this discussion.”

She nodded and looked toward the bed where she threw her purse, “My gun is in my purse.”

“You smuggled a gun into the courthouse?”

“I always have a firearm handy,” she said nonchalantly.

“Strange,” Diaval muttered and then rolled to his couch a foot away and hit the side panel of the base. The panel slid out and pulled a small glock with a silencer.  He handed it to her and then pulled out a rifle with the same outfitting before he closed it up again.  He checked for ammunition and then looked back at her again, “I'm the same way.”

Her eyes were so large at that point, he didn't know if they were going to fall out of her head.

“Get this guy off our tail and then we have a long night of questions ahead of us. Agreed?”

“Agreed,” she breathed out.

“I'll take the East window.”

“I'll take the West,” she nodded and they both crawled toward their windows.

“Think you know who it is?” Diaval asked as he carefully set up his rifle and looked out the scope.

“If I had to guess, it would be Borra,” she explained and tried to get a good feel on where he was set up, “If there was anyone that would take the contract on you and get to take me out as a bonus, it would be him.”

“Type?”

“Bulky, likes his muscles and rifle do the talking,” Mal growled, “Not much going on up stairs.”

“Good, won't be as big of a mess.”

“He's on the Southern edge.  Laser scope.”

“I see him,” Diaval focused his sight and just as the laser pointed his way again, he squeezed and no more laser.  No more shooter.

“Hold for a moment,” Mal said before either of them moved from their places.  A second lazer came into view from a story down from Borra, “There is another.”

“Yeah, I see the end of the rifle, but not them,” Diaval frowned and leaned back, “They have a better shot at me then I do of them.”

He heard the soft shot through the silencer from his other window.  The end of the other rifle fell back and then it was still.  He looked over her Mal who shook her head and stood from her spot at the window.

“You hit them with the glock?”

“I had a shot,” she said as if he had insulted her, “Give me some credit.”

He finally shut his window and walked over to shut hers, “Okay, so questions and answers.”

“How?” she asked and held up the glock, “You're a food critic.”

“Part-time food critic,” he corrected and took the glock from her before he went to put it back into the couch hide hole, “You know how I wasn't worried about assassins?”

“Yes, I thought that you were being way too under prepared for it.”

“Ever heard of Black Feather?”

“That's you?”

He laughed, “I really had hoped that they would pick up on the feathers left on the bodies belonged to a raven, but when you leave it to the media to name you...”

“Raven... you and ravens,” she shook her head and sat on the back of the couch to face him.

“Like you should talk,” he smirked and sat next to her, “Phoenix.”

“How long have you known?”

“Since you picked me up from the police parking lot,” he admitted and looked at the floor at their feet, “I knew that someone was after me when my break lines were cut.  Then a gorgeous woman takes me to lunch out of no where?  What did you have behind your back at the car?”

“Injectable nightshade,” she said quickly as if to soften the blow, “You saw me quick.  I'm glad you did.”

“Good trick with the jacket at the bistro,” he shook his finger at her, “Would have tricked most men.  I'm sorry I didn't stop you from eating that second slice.  I thought that you knew which slices were safe to ingest since you put the poison on there.”

She laughed under her breath, “Yes, that.  I got distracted.”

“Oh, how the tables have turned,” he smiled and bumped her shoulder with his, “I distracted you into poisoning yourself.  That is a new one.”

“Stop that, you insufferable raven,” she rolled her eyes at his laughter and looked at his profile, “Then you knew what I was doing after that day.”

“You probably tried to get the gang to call off the hit on me on the days following our meeting,” he guessed at which she nodded and then he frowned, “But once you found out someone else tried to take up the bounty, you came to keep me out of harms way- you know, I thought those were bullets hitting behind me.”

“They were.”

“What changed from today where they targeted you too?”

“Stefan,” she shook her head and her teeth ground together, “He put the hit on you to begin with, just like the other men who were caught in that coffee shop with you.  He asked me to take care of it.  When he saw me with you today, he finally realized that I truly wasn't going to go through with it.  I wasn't going to kill you.  I was going to protect you.  I then became the second target.”

Diaval took a moment and finally looked back at her, “Not that I'm glad you didn't keep trying to kill me after your disastrous first attempt, but why didn't you?”

She looked at him, deep in his dark eyes and shook her head, “I was being stupid and reckless and sentimental...”

He chuckled and she laughed lightly with him.

She took his hand in hers to poke at his palm, “And, I may just had fallen in love with you.”

“After that first day?”

“No, I knew you were a good man after that first day,” she rectified and kept a hold of his hand, drawing over the lines in his palm, “Then I got to know you, and Rory.  More and more and it just grew.  You were the first one to genuinely ask after me.  About me.”

Her head suddenly lifted in a single notion, “You did want to know me?”

“Yeah, I did,” Diaval nodded and pulled at the hand that was in his, “I still do.”

“After everything that I told you?  After you know what I am?”

“A killer just like me?”

“You kill the bad guys.  You're a vigilante and a hired gun for those you deem worthy. I've read up on you,” she smirked, “The blood on your hands is merited, mine is dirty... so very dirty.”

“Blood is blood. We've both done things that we regret- some things that we will never speak of because we think it will label us monsters.  Things we blame ourselves for.  I know your track record too.  Every single target,” he answered and took a deep breath.  He put an arm around her shoulders and pulled her tight to his side, “The worst part is, I love you anyway.”

She smiled up at him and then leaned her head on his shoulder as he hugged her to him.

“I need to let you know something,” he whispered into her hair above her.

“More?” she asked as she pulled away.

“Yeah,” he squinted and rubbed the back of his head, “I was supposed to kill you too.”

“What?” she frowned.

“After you killed me, actually,” he chuckled a little, “Stefan tried to contact Black feather to take out another hit man after they finished with their target.  He wanted to tie up loose ends.  I think he figured out that wasn't going to happen either.  He kept asking, I kept ignoring him.  He finally gave up.”

“So, we were asked by the same man to kill each other?” she asked and narrowed her eyes at him, “I think that we should at least let him know that the contracts cannot be completed.  Don't you?”

“Absolutely,” he nodded as she tried to pull away from him.  He caught her arm and pulled her back to sit in front of him, “But before we do-”

She looked at him in question until he leaned forward and kissed her.  His hand lifted to gently caress her cheek and fingers gently stroked the hair pinned behind her ear.  She smiled into the kiss and wrapped her arms around his neck to pull him closer.  She nearly crawled into his lap as he tried to steer them to the bed.

Much later that night, they found themselves wrapped in the sheets in his bed as they planned their first of many team contracts.

[teachingrounds]

Allergic-like reactions to IV contrast

Allergic-like reactions to IV contrast are similar to other allergic reactions although the mechanism has not been established. Acute mild and moderate reactions may require only supportive care, although these can progress to severe and patients should be closely monitored. Epinephrine IM (0.3 mL of 1 mg/mL) or IV (1 mL of 0.1 mg/mL) is recommended for severe reactions (bronchospasm refractory to inhaled Beta-2 agonist, laryngeal edema, anaphylaxis). IV atropine is recommended for hypotension with bradycardia.

Patients with history of mild or moderate allergic-like reactions (not physiologic reactions such as vasovagal or seizures) can be premedicated with oral corticosteroids. History of severe reaction is an absolute contraindication to receiving the same class of contrast (iodinated or Gd-based) unless the benefits outweigh the risk.

Reaction to iodinated contrast is not a contraindication to receiving Gd-based, and vice versa (and no premedication is required).

Read more, including premedication regimens, in Chs. 4, 7, and 14 of the ACR Contrast Manual.