Parkland Hospital lives with the contradictions of fentanyl every day. For decades, doctors have relied on the opioid to treat patients' pain. But now, illicit use of the drug has become a public health crisis the hospital is trying to combat.
Deep in the belly of Dallas County’s only public hospital, a pharmacy technician badges in and enters a labyrinth so restricted that few in the hospital have ever seen it. Cameras monitor her movements as she makes her way among towering shelves of plastic bins filled with syringes and needles and vials to another door — a door so plain it could belong to a forgotten supply closet full of surplus toilet paper and Styrofoam cups. Here, she reaches for her badge again.
The rest of the 882-bed hospital begins to hum as a new batch of bleary-eyed staffers file in to start their day shifts. In the intensive care unit, nurses switch out bags of saline and fentanyl on the IV stands of the hospital’s most critically ill. In palliative care, pain management specialists review files on the patients who will receive fentanyl patches. In the NICU, nurses assess each baby. Even the smallest sometimes get fentanyl for invasive procedures, in impossibly tiny doses.
The woman lying unconscious in the farthest room of the ICU was sedated, her chest rising and falling mechanically with the help of a ventilator. She could not see the fresh flowers on the windowsill. But the younger woman sitting near her hoped she could sense, in some way, that she wasn’t alone. The IV pole was laden with infusion pumps, steadily dosing medication into the central line in the patient’s upper thigh. One of those was fentanyl.
When McRae punched her security info into the computer, a large shallow drawer popped out. Like a high-tech vending machine, the system ensures a nurse can take only the drug needed. Nurse Kim Mai took a deep breath. The family sounded so shocked. But she was getting this question more frequently. Parkland stocks a variety of fentanyl, including vials of liquid, transdermal patches and premixed bags for IV lines and epidurals. The inventory does not include fentanyl in tablet form.
Parkland tests an average of nine people a day for fentanyl. Last July, 14% tested positive, he said. This July, the positive rate was 38%. As a licensed clinical pharmacy pain specialist, her job is to understand how much they hurt and why. People with devastating new diagnoses often feel physical and emotional pain, she said. Chamberlain helps determine how much medication they need.
One of the patients on her list Tuesday was seeking relief from chronic pain from a back injury and abscesses from years of drug use. This patient, like a growing number of the patients she sees, was addicted to fentanyl and could not receive opioids for pain. Doctors always try Narcan first. “We see how they respond to it,” said Dr. Jeff Metzger, chief of Emergency Services. “If that works, we continue down that pathway.”Identifying the substance isn’t the first concern for Metzger’s team. In those life and death moments, an opioid is an opioid. Seldom do they need a drug screen to determine whether it’s an opioid rather than, say, cocaine or meth.
When she arrived the day before, she told the staff she had used right before getting to the hospital, and she needed help. “They come to get this help knowing that they are going to feel sick, and they stay anyway,” said Jessica McNeil-Santiel, a nurse midwife and addiction medical provider. “They want to do what is best for their baby. They want to do the right thing.”
They come to get this help knowing that they are going to feel sick and they stay anyway. They want to do what is best for their baby. They want to do the right thing.”
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