"The heart doctor has those people who refuse to change their diets. Emergency medicine docs, we have the drug abusers."

If Erin isn't dead, then she's pretty close.

Fifteen minutes ago, her lips and fingertips had been blue when emergency medical technicians arrived at her parents' Wilkes-Barre home. Her mother had found her unconscious on a bedroom floor. She had taken enough of a powerful pain medication called fentanyl to level a large man.

A beige telephone in the Wilkes-Barre General Hospital Emergency Room rings at 10:30 on this July night.

Nurse Mariellen McGough activates the speakerphone and writes Erin's information on a white form inside a large binder. The male EMT calmly describes Erin's condition using words such as "unresponsive," "not breathing" and "overdose."

Dr. Brian Saracino doesn't just deal with overdose victims in the Wilkes-Barre General Hospital Emergency Room. Here he examines an infected foot.

Dr. Brian Saracino, right, tries to figure out how much fentanyl an overdose victim named Erin took as nurses Allison Knick, left, Sandy Redmond, center, and Jennifer Mooney, right, attend to her in the Wilkes-Barre General Hospital Emergency Room.

Mariellen McGough and Ron Redmond take information down heard over the radio on an ambulance call on its way into Wilkes-Barre General Hospital.

A large part of emergency medicine is filling out charts. Here, Dr. Brian Saracino tends to his paperwork while he consults with another doctor on the telephone.

Nurse Allison Knick updates the triage board during a shift at the Wilkes-Barre General Hospital Emergency Room. The board is meant to keep track of patients and their status.

Dr. Frances Feudale talks with a patient who stepped on a nail. Later in the evening, Feudale helps a longtime heroin addict check into the hospital's detox center. Of drug addicts in the emergency room, she said, "When you see these overdoses that are coming in, not only are you taking away emergency resources from the community, but you're taking away from the true emergencies in the ER at that time."

Dr. Brian Saracino is one of two physicians working the late shift. He tends to a stack of papers as the nurse logs Erin's information, but leans his head back slightly to listen.

Dr. Frances Feudale, a short 39-year-old woman in a brown sundress, decides to let Saracino treat Erin while she grabs dinner. She turns away from her takeout pasta, wipes her mouth with a napkin and says to Saracino, "I'm going to eat, Brian. That one's yours."

Erin, whose last name isn't released due to hospital privacy restrictions, attends graduate school in New York City. She's in town visiting her parents. This overdose isn't a suicide attempt. Saracino learns later that Erin has a history of narcotics abuse.

In the trauma room

Paramedics roll Erin's body into a trauma room. The room is much larger than others so more staff members can treat a patient. Shelves of medical supplies and a spider web of wires and equipment surround Erin in the brightly lit room.

From the minute she arrives, Erin is the top priority of about eight ER staff members.

As the nurses gather over Erin, Saracino sits in the nearby administrative pod, a collection of computers and rolling desk chairs where doctors and nurses can see all the beds. He casually stands up and meanders to the trauma room.

"Let's say it all together: 'recreational misadventure,'" he says as if leading a chorus of children in a nursery rhyme. He pretends to conduct with his index finger, but everyone else is too busy to sing along.
Saracino stands 5 feet 7 inches tall with coal-black hair, highlighted with flecks of gray. He's dressed in blue doctor's scrubs and matching blue and gray Nikes with air soles to cushion his feet during long periods of standing. His eyes bear a weight of constant fatigue.

He's a family man with a wife and three children. He enjoys hunting and often pulls out a color photo of himself standing over a dead 800-pound feral pig. He sometimes shows patients the picture to give them something to think about besides being in a hospital.

In the woods, he kills, but in the ER, he must try to save every patient.

Assessing the patient

"Did you check her mouth?" Saracino asks one of the EMTs.

Fentanyl abusers sometimes chew the opiate patches to ingest the time-release medication more quickly.

The EMTs tell Saracino that they checked her throat before they arrived at the ER. Erin stuck the patches on her body.

The EMTs had resuscitated Erin before she was brought to the hospital and her condition remains critical.

She still has a lot of fentanyl in her system. She could lapse into unconsciousness at any moment.

Emergency room technician Ron Redmond leans in over the right side of Erin's gurney.

"Hi, wake up for me," Redmond asks quietly. "What happened to you?"

ER staff members appreciate Redmond's ability to connect with patients and the gentle way he gets them to speak. He's a tall man in his late 30s with a pointed nose, narrow face, salt-and-pepper hair and maroon scrubs.

Erin struggles to talk. She looks around the room and casts a bewildered stare at the doctors and nurses.

"I have no idea," she replies, the oxygen mask that covers her nose and mouth muffling her voice.

"What's the last thing you remember?"

Though she seems awake, she doesn't respond.

The nurses pull Erin's navy blue dress over her head, exposing her maroon panties. The nurses struggle with the dress. As they pull it over her head, it snags on one of her elbows. A female nurse removes Erin's pink bra and covers her with a flimsy light blue hospital gown and sheet.

Saracino picks up a small white box of fentanyl patches that's on the bed next to Erin. The EMTs found it in her bedroom. Saracino pulls out a single patch. From the box of 10, only one remains. They found three stuck on Erin's body. Six others are missing.

Powerful painkiller

Fentanyl is an opiate that doctors say is about 10 times stronger than a typical morphine dose. The time-release patches are given to late-stage cancer patients or people who claim to suffer from severe chronic pain, such as Erin. A single patch is meant to last three days, meaning Erin absorbed at least nine days worth of medicine at once.

It's enough fentanyl to kill a 250-pound man, let alone this 100-pound woman.

"You almost died. That's why we follow the directions on the box," Saracino tells Erin, though she doesn't respond. He continues to pelt her with questions.

"Erin, do you do any illegal drugs?"

"No, I'm a good girl."

"And you weren't trying to hurt yourself today on purpose?"

"No."

If Erin shows signs that she's suicidal, the doctors can commit her for a psychiatric consultation without her consent.

Nobody can force Erin into drug rehabilitation. And because she's not suicidal, Saracino can only keep her in the hospital until she's medically stable.

Doctors use a drug called Narcan to neutralize the effects of drugs such as heroin and fentanyl. It blocks fentanyl's ability to stimulate the brain's opiate receptors. It also causes patients to immediately go into withdrawal.

"I'm going to give you something that will make you better," Saracino says. "This might make you sick so I'm going to give you a bucket." Erin mumbles something inaudible as Saracino leaves her in the nurses' care. He must begin filling out paperwork.

A nurse injects Narcan into the IV tube that hangs from Erin's left wrist.

It's about to get messy in the trauma room.

Treating addicts

Drug overdoses are only one part of the drug-related problems that ER doctors encounter. Car crashes, drug-related shootings, suicide attempts and stabbings also result from drug abuse.

Saracino and Feudale said that on some nights, they treat as many as three overdoses.

Addicts stumble through the door and pass out in the waiting room. Savvy junkies come in with fake ailments in an attempt to scam doctors out of pain medication prescriptions. Strangers dump their overdosing friends in the ER's patient drop-off area and speed away. One man drove to the ER five times in one night to drop off people from the same party who had overdosed on heroin laced with fentanyl.

"One actually died," Saracino said. "The others, we were able to revive."

It's difficult to quantify the number of people treated for drug-related overdoses in the Wilkes-Barre General ER each year. Saracino said the hospital's computer systems are antiquated and the statistics aren't tracked.

The federal Substance Abuse and Mental Health Services Administration estimates that, of nearly 2 million drug-related emergency room visits in the United States in 2004, nearly 1.3 million were associated with drug misuse or abuse.

Nearly 50 people in Luzerne County die annually because of drug overdoses, according to coroner statistics from 2002 to the present. And, then, there are those who survive.
Messy situation

Within minutes, the Narcan starts to work. Mauve vomit sprays from Erin's mouth, soaking her gown, hair and the linoleum floor. Nurse Allison Knick rushes into the trauma room and uses a tube to suction the vomit from Erin's mouth so she won't aspirate, which occurs when people inhale vomit.

Outside the trauma room, Saracino unveils a container of homemade salsa that he brought to share with the ER staff. One of the nurses is leaving to start medical school so the staff organized a makeshift potluck. Saracino scoops a generous helping of tomato dip onto a tortilla chip before he walks into the trauma room, which is covered in vomit.

He chews his food while he examines Erin.

A nurse mops away the mess as Erin's condition stabilizes. Another adjusts the bed so Erin can sit up. A nurse leads Erin's red-eyed mother into the trauma room. She takes a seat near her daughter's bed and they sit in silence, saying little, if anything.

Choosing the ER

After serving in the military and eventually earning a medical degree, Saracino took a job with Sapphire Medical Group, which will provide physicians, nurse practitioners and physician assistants to Wilkes-Barre General Hospital until the end of the year. A new medical group will take over ER staffing in January.

Saracino and Feudale chose emergency medicine because of its fast pace. They can see a patient, make a diagnosis, prescribe treatment, and send the person home usually within a few hours.

The time ER doctors spend with their patients is fleeting compared with family practitioners or specialists. Alcoholics and drug addicts are the ER's regular patients. While broken bones heal and stitches come out, drug and alcohol recovery requires serious commitment from patients.

"We offer everybody different avenues for help, but I don't think anybody is going to influence that person to change until that person wants to change," Saracino said. "I'm not sure it's our place to judge. My job starts when they come into the emergency room. It ends when they leave."

Feudale works in the emergency room on a per diem basis. She's also the director of the King's College physician's assistant program.

Feudale said she felt more interested in helping addicts when she began working in emergency medicine. Now she considers them more of a distraction than anything. While the staff tends to overdose cases such as Erin, other patients are forced to wait.

"I knew when I signed on to doing emergency medicine, this was part of my clientele. As any doctor, you're very optimistic, I can bring people back to life from a heart attack, I'm going to deliver babies, I'm going to help drug abusers get into rehab," she said.

"Unfortunately with alcohol and drug abusers, you lose more than you win. Every specialty has a group. The heart doctor has those people who refuse to change their diets. Emergency medicine docs, we have the drug abusers."

The doctors must still try to save everyone who comes to the ER, though not everyone offers thanks for the help. Some patients react angrily to doctors because they've ruined their costly high. Occasionally, junkies rip the IV needles from their arms and storm away from hospital.

Many addicts don't want their families to know they have a drug problem. People with high-paying careers worry that if someone finds out about their drug use, they'll lose their jobs. Sometimes, lying nearly naked on a hospital bed with wires and tubes hanging from your body is just embarrassing.

"You're trained to deal with people who need your help, but here you have people who harm themselves intentionally and, when you fix them, they don't want your help anyway," Feudale said.

Treating Jennifer

Feudale comes across a chart at about 12:15 a.m. for a heroin addict named Jennifer, whose parents brought her to the hospital.

Feudale startles Jennifer from her sleep. She's covered with a stiff white sheet up to her neck, her body in a fetal position. Bed pans sit at her feet and near her head, one filled with spit and vomit. Jennifer recently snorted four bags of heroin, but hasn't done drugs in a day. She's in the throes of withdrawal.

Feudale softly asks a series of questions.

"Do you do any other drugs besides heroin?"

"Cocaine."

"You smoke cocaine?"

"Yeah."

"Do you ever shoot up?"

"No."

"Drink alcohol?"

"Once in a great while."

Jennifer wants to be admitted into the hospital's outpatient drug rehabilitation program.

Her frame is gaunt and absent of muscle. As she turns over, the end of her ulna that nub of bone on the outside of her wrist stops a gold bracelet from falling off. Her face is pockmarked. These are all signs of long-term drug use.

"You've been in detox before here, right? How long ago?"

"Eight months ago."

"Was it your first time in detox?"

"My second."

"Just this past October (2005)? And are you thinking about hurting yourself?"

"Right now I just want to tear the skin right off my body."

"How many times have you thrown up?"

"I don't know how many times," Jennifer says, looking at the plastic banana-shaped basin. She says she threw up just before Feudale came in.

"Are you getting your period?

"No."

"When was the last time?"

"Three years (ago)."

Longtime heroin users often don't menstruate.

Feudale learns that Jennifer, like many addicts the doctor sees, began abusing prescription drugs after a doctor gave her something for pain after a car crash. When the prescription ran out, she turned to illegal drugs such as heroin and cocaine.

Feudale asks Jennifer to sit up. She places the cold stethoscope on Jennifer's frail back as the emaciated woman takes three labored breaths. Patients who want to be admitted to the detox clinic must receive medical clearance, which means they often come to the emergency room first to see a doctor.

"We'll get you some help, hon," Feudale says softly as she gently brushes Jennifer's hair.

Space in the detox clinic is limited to 10 people, and men and women are separated. Jennifer is escorted to a room where she'll sleep on a cot surrounded by other addicts waiting for a detox bed. She'll give recovery a third try.

Erin goes home

Saracino admits Erin into the intensive care unit after she spends about five hours in the emergency room. Erin will be monitored overnight.

Erin walks out of the hospital Sunday morning with her mother. The doctors kept her alive. She must decide whether she wants to continue to live. All the emergency room doctors can do is point her in the right direction and try to save her again if she returns.