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"Fractals, fractals inside of fractals, and Asian doctors guarding the gates to eternity, little prisms, little prisms of gnomes, multicolored gnomes surrounding me, doctors with the keys, the key to eternity." I'll never forget those words that wished me goodbye as I left the hospital.
The launch of my second year as an EM resident began at San Francisco General Hospital and did so in relative peace. I began the day with trepidation and excitement and was surprised to arrive at an empty ED at 6am. Perched in the middle of SF's mission district, SFGH sees much of the city's traumatic injuries including penetrating trauma like gunshot wounds and stab wounds as well as many of the city's pedestrians that are too often hit by autos.

An empty ED is also scary because it will inevitably transform into a vortex. And on my first day it did. My friend, the mathematician, the one seeing fractals was about 20 years old, found in a park, shooting something as incoherent and intriguing as this when the police picked him up and transported him to SFGH. His voice was definitely the loudest in the cacophony at the end of my 12 hour shift. There were others, intoxicated, swearing at us and not happy to be in the ED. Also a the shouting in the trauma bay from an incident similar to the one I wrote about two blogs ago.

On my way home, having not seen the trajectory of his case, I wondered about what he might have ingested. My first thought was LSD or PCP because of the intensity with which he was fighting the cops and screaming about fractals.

LSD is a potent drug requiring only 1 microgram to have psychedelic effects. Usually a dose is distributed as blotter acid squares in 25 microgram proportions. If he did ingest acid he would not be near the lethal dose which requires 14,000 micrograms. Though his trip would not be pleasent because it usually lasts 12 hours, peaking in the first 4 hours, unlike mushrooms (psilocybin) that peaks in the first 30 minutes to 2 hours and wanes by 4-6 hours.
Still, his eyes were not as dilated as they usually are with LSD ingestion due to a sympathetic nervous system response. He didn't have the ataxia (uncoordinated), nystagmus (eye twitching) or increased secretions seen with PCP. At least his vital signs were normal, with a normal blood pressure, temperature, heart rate, and respiratory rate, so we felt more comfortable focusing on calming him down. After I left the hospital I was told that he needed four police officers to be restrained and sedative medications in voluminous quantities.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.