Living and Dying in Brick City (5 page)

Our pharmacy network lent a hand in helping to keep track of how many times a particular medication had been prescribed to an individual patient. Repeated narcotic prescriptions always raise a red flag, particularly if they come from different doctors. I received calls on numerous occasions from pharmacists alerting me that someone who had left the emergency department with a prescription written by me had recently been prescribed sixty
tablets of the same medication by a doctor at another medical facility.

Then the pharmacist would ask: “Dr. Davis, do you still want me to fill the script?”

My response was always the same: “No, and I will notify my department so they’re on the lookout.”

There were times I tried to claim small moral victories, quietly reducing the dosage of the pain medication the staff administered to a patient I suspected of abuse, or refusing to send the patient home with a prescription for Percocet or OxyContin. Other times, I refused to give the third dose of Dilaudid, insisting instead that if the patient was still in pain, he needed to be admitted into the hospital. My refusal to follow the unwritten rules occasionally resulted in blowups. A patient would protest loudly, curse me out, and sometimes even trail me around the department, threatening to call the state to complain about poor treatment and a lack of respect.

That was sort of how I wound up one sunny spring day in 2002 sitting in the emergency medical director’s office. The discussion was to be my quarterly Patient Satisfaction Review, a survey that had become the latest trend in hospitals’ frantic quest to generate business in an era of budget cuts and reduced services. How satisfied a hospital’s patients were played a large part in its reputation. My scores, normally above average, had fallen a bit, I suspected because of my growing impatience with drug seekers. I arrived early for the meeting, and Dr. Fink’s secretary was kind enough to allow me to wait in his office. With coffee in hand, I stood mesmerized by the degrees, board certificates, and awards filling his wall. The office, located on the top floor of the hospital, offered a panoramic view of the Newark skyline, a sea of tall brick buildings interspersed with small patches of green. Far off in the distance, you could see New York City. Less than a year earlier, I’d
watched the aftermath of the September 11 terrorist attacks from this window.

As I waited, I rehearsed in my head what I would say when Dr. Fink instructed me to be less confrontational. I would hear him out without agreeing to change my position. I would point to literature showing the rise in prescription drug abuse. I was not a drug dealer.

I glanced at the framed photos on the director’s mahogany desk. There were pictures of his family, his dog, and buddies dressed in army fatigues. I recalled Dr. Fink saying once that he was an army dude. I leaned in a bit to look more closely at a photo of him with his two sons, a black-and-white shot that had been taken outside, maybe while fishing or camping. The boys appeared to be close in age and tall and slim, like their father. Suddenly, without warning, Dr. Fink, a man in his fifties with just the right amount of salt-and-pepper hair to equal his experience, entered his office. Embarrassed, I straightened from my detective position over his desk.

Moving to his chair, he sat and motioned for me to take a seat across from him, which I did. He then said: “How are things, Sampson?”

“Things are well, Dr. Fink. No complaints,” I responded, keeping my cool.

“You know, Sampson, medicine is a great field,” he began, then continued for a few moments, talking about how doctors gain extraordinary wisdom from what we see in the field.

I nodded in agreement, waiting to hear where he was going with this conversation. We both were busy. And he hadn’t called the meeting to talk about the joys of medicine. Dr. Fink must’ve seen in my eyes that I was eager to get on with it, because he quickly got to the point. “Sampson, do you know why you’re here?”

Again, I nodded.

“Well, let’s just say, when you’re dealing with cases that are not
actual emergencies, try to imagine one that truly moved you. I know you have plenty, so I won’t ask you.”

He paused. I was puzzled, and feeling a bit like I was in the principal’s office—I half expected my mother to come tearing through the door any minute, belt in hand.

I asked, “Is that it?”

“Yes, that’s it. Take care.”

Still slightly confused, I rose from my seat and left the office. Dr. Fink was a child of the seventies. Had I just experienced a hippie moment?
Live peacefully and think of memorable cases
. I laughed quietly all the way back down to the emergency department. It was an unexpectedly light moment in a frustrating scenario.

I
often referred—or tried to refer—patients to the hospital’s social worker for pain-management counseling or to the psychiatry department for narcotics-abuse treatment, with the hope that they would get the help they truly needed. But there was not enough staff to handle the need, and there were rarely any available beds in the psych ward. And even when a room opened up, the patient held the upper hand: Nothing was mandatory. If he denied having a drug problem, he could refuse an intervention or check himself out of the hospital at any time, which is what usually happened. Beth Israel’s pain-management counseling tried to address the issue broadly, but many patients wouldn’t show up for scheduled sessions or refused to even make an appointment. Many patients didn’t see themselves as addicts. In their minds, an addict was the crackhead uncle begging for money on the corner or the strung-out sister pawning their parents’ possessions.

Because of the staff’s heightened suspicions, I’m sure there were times when patients who were hurting and needed relief were wrongly viewed as addicts, as well as times when addicts with real illnesses were indeed in pain. In those cases, they most likely received
the appropriate medication and treatment, but perhaps with a little less compassion than they deserved. That is one of the heartbreaking fallouts of this dilemma.

No one was suspicious of Mr. Jacobs, though. He was an Afro-centric, Malcolm X–looking dude in his late fifties who usually wore an African dashiki and matching kufi cap. A couple of times I saw him receiving treatment in the emergency room late at night in his pajamas and robe. He carried himself in a dignified manner, and the staff treated him with deference and respect.

When I first met Mr. Jacobs in 2002, he mentioned the memoir I’d just written with George and Rameck. “Man, I heard about you young brothers,” he told me. “You’re doing great things in the community.”

At his age, Mr. Jacobs seemed like a modern miracle. He had lived more than a decade past the life expectancy of a man with sickle-cell anemia. (The average for a man with the disease is forty-two years; for a woman, forty-eight.) Mr. Jacobs kept up with the latest news, and whenever I saw him at the hospital, he talked about the racial politics of the disease, the need for more research, and how sickle-cell anemia always seemed to draw the short end of the stick when it came to government funding. The latest statistics and research rolled off his tongue. Mr. Jacobs told me that he had founded a small support group for sickle-cell anemia patients and their families and asked if I would speak at a future meeting. I agreed without hesitation. But we never nailed down a specific day. One thing seemed a little odd to me: For someone who had founded a group on behalf of those stricken with the disease, Mr. Jacobs never seemed to mingle with any of the other sickle-cell patients.
Maybe he’s suspicious of some of them because they seek drug treatment so frequently
, I thought.
Maybe he’s worried that their actions might reflect badly on his group
.

Sometime later, Mr. Jacobs was admitted to the hospital. The
internist on duty that day ran a series of blood tests, including a routine screening for sickle-cell anemia. When the results came back, everyone was shocked: Mr. Jacobs did not have the disease; instead, he was simply a carrier of the trait, which in most cases causes no symptoms, or minor ones, such as anemia. Over the past decade, researchers have found that in rare cases, a person with the trait may experience severe exhaustion, greater rates of urinary tract and kidney infections, and, in isolated instances, even episodes of pain similar to the disease. Was Mr. Jacobs an anomaly? Or was he just a more dignified drug addict? I will never be certain, and as far as I know, nothing ever changed with his treatment. That’s the most maddening part of the dilemma.

There have been hopeful moments, though, like when I met fifteen-year-old Patrick. He was the color of cedar, with bright, happy eyes—and he was also the size of an average ten-year-old. The lack of adequate blood flow throughout the body sometimes stunts the growth of sickle-cell patients. Patrick’s mother, Janice, brought him to the emergency room one day with debilitating pain in his back and knees. He could barely walk.

Janice was in her mid-to-late thirties, with a bubbly, young personality. She seemed hip to the latest styles of clothes—looking put together in her jeans, heels, and leather jacket. More important, I could tell by the thorough way she answered my questions that she was hands-on with both her son and his medical care. She explained that she’d given him ibuprofen and his prescribed pills earlier, when he’d first complained of pain, but he hadn’t gotten any better. After examining Patrick, I told them I’d decided to start him on a small dose of morphine. His mother interrupted.

“Oh, no, Dr. Davis!” she said. “Don’t give him morphine.” She asked if he could start his treatment with Toradol, a non-narcotic anti-inflammatory prescription pain reliever similar to ibuprofen. But Toradol comes in a liquid that can be administered through an
IV, which some patients believe brings relief faster than a pill. “He usually does fine with it,” she added.

While Patrick’s pain certainly seemed severe enough to merit the morphine, his mother had the insight to know that giving him narcotics too soon could be problematic later. I wanted to hug her. With her involvement, he had a better-than-average chance of staying on track.

Patrick reminded me of another teenager, Wayne, whom I’d met in 1999, my first year of residency, when I worked on the pediatric side of the department.

The basic facts matched. Wayne, too, was an African American teenager with sickle-cell anemia, and had come to the hospital with a woman, who I presumed was his mother. But that’s where the similarity ends. As I examined Wayne, the woman seemed to fade into the background. And when I asked about his pain or prior medications, he responded himself.

A short, round dude, he was unusually thick for a sickle-cell patient. His hair was braided in neat little cornrows; after that first visit, it was braided in a different style nearly every time I saw him. That day, Wayne was experiencing serious pain in his back and knees. I treated him with a dose of Toradol until the pain subsided. The teenager was upbeat and chatty, even in pain. The few times a year I saw him after that, I’d treat him with the maximum amount of Toradol and release him when the pain subsided. If his pain didn’t respond to the Toradol, I added a small bit of morphine. That approach seemed to work well; it kept the narcotics to a minimum and eased his pain. This is a common strategy in treating young patients with chronic pain.

When Wayne turned eighteen, I could no longer treat him on the pediatrics side. He was moved into the department’s general population, and he came to the hospital alone. It was not uncommon to have three or four sickle-cell anemia patients receiving
treatment at the same time on any given day; whenever possible, the medical staff grouped them together to make the frequent monitoring more convenient for the nurses. Because of crowding and the reality that sickle-cell patients were usually there all day, their stretchers most often were lined up, head to foot, against the wall on the O side of the hallway, the observation area for stable patients. I began to notice Wayne mingling with the others.

It didn’t take long before he started showing up in the emergency room more frequently—changing from every few months to once a month to every other week. Then he began complaining that the Toradol wasn’t easing his pain at all. I wasn’t on duty each time he came to the emergency room, so I didn’t see it personally, but his chart told the story: one milligram of Dilaudid, then two, then four, and on and on. In just over a year, Wayne had gone from taking almost no narcotics to receiving ten milligrams of Dilaudid, the maximum dose. And the newest member of the posse learned well. He began instructing the duty doctor on how much medication he needed, and if the doctor ordered less, Wayne would follow him or a nurse around the department, demanding: “This is not my proper dose. I am in pain, and you need to give me my proper dose!”

By the time Wayne turned twenty, he had progressed to taking three rounds of the maximum dose of Dilaudid. One day, after his third dose, he said he was still in pain. He agreed to be admitted to the hospital and was transferred to an inpatient room. During one of her rounds, the nurse found Wayne lying motionless in bed. His chest wasn’t rising. She felt for his pulse. Nothing. His skin, normally a golden color, now appeared dull and dusky. She buzzed the nurse’s station, which called a Code Blue, and within seconds the medical response team was at his side, working to resuscitate him.

But it was too late. Wayne was dead.

It was spring 2002, and when I arrived at work the next day, the staff was still buzzing with the news and speculation on what had happened.

“Did you hear about Wayne?” someone asked, then filled me in.

I was startled. Even though I’d watched from a distance Wayne’s tragic transformation from sick kid to drug addict, I hadn’t seen this coming. There were rumors that he had either cocaine or heroin in his system as well as the Dilaudid that final day, or that he’d injected a street drug into his IV, trying for a faster, more intense high. As far-fetched as that may seem, there had been a similar incident in 2000, late in my first year on the job.

That patient also had sickle-cell; but, in addition, he bore a laparotomy scar from some type of surgery to his abdomen. The few times I’d encountered him in the emergency department, he was rubbing his belly, complaining of severe pain in his scar area. He was a grumpy dude, who barked orders at the staff: “Gimme my pain medicine, now!” His last day, he was in a room on the inpatient side when the nurse found him, unresponsive. A bottle of Robitussin was at his bedside. The staff suspected he had injected the cough syrup into his IV.