Living and Dying in Brick City

by Sampson Davis

  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.

  I never learned for sure what happened in either suspicious death. At the time, I was shocked. But recent studies show that prescription drug abuse is the fastest growing drug problem in the United States, and deaths from overdoses of prescription painkillers are on the rise. In a November 2011 report that examined such deaths from 1999 to 2008, the Centers for Disease Control and Prevention called the problem an epidemic, saying that prescription drugs are behind the overall increase in drug overdose deaths. Even more startling, a greater number of people are dying from overdoses of prescription drugs, such as OxyContin and Vicodin, than from cocaine and heroin overdoses combined. The rise in prescription drug overdose deaths has been so steep that by 2008, they were approaching the number of deaths from motor vehicle crashes, the leading cause of injury death in the United States.

  A few weeks after Wayne died, I learned that another of our sickle-cell patients was his sister. Her name was Sarah, and she was in her mid-twenties, a few years older than Wayne. She had come to the emergency department for pain treatment that day and mentioned she had been struggling with depression since her brother’s death. Though Sarah and Wayne shared the same last name and had similar features—short and round with gold-colored skin—I’d never seen them together and hadn’t until that moment made the connection that they were siblings.

  “I didn’t realize Wayne was your brother,” I told her. “I’m really sorry about what happened.”

  Sarah, who always spoke in a soft, babyish voice, seemed distant and withdrawn. After that day, I noticed, she began careening downhill. I’d sometimes catch a glimpse of her, looking haggard and beaten down, a baseball cap or scarf pulled over her head, in a drug-induced sleep—or sitting in a daze on a hallway stretcher. This was doubly sad. Not only did both siblings have the same terrible, life-shortening disease, they both became addicted to painkillers … and perhaps more. I knew nothing about the siblings’ lives and struggles beyond the hospital, but I grappled with this question: Did we do more harm than good? We were supposed to help our patients, or at least do no harm. That’s what all doctors promise when we take the Hippocratic Oath.

  As time went on, I grew more and more vocal among my colleagues with my complaints about the drug seekers and the anguish I felt prescribing narcotics when I had serious doubts about whether the patient needed it. One day, a fellow doctor blurted: “Just write the prescription. Why do you even care?”

  I pondered that question the rest of the day: Why did I care?

  The answer boiled down to this, I realized: When I was a naïve, impatient teenager, I’d walked away from drug dealing. I’d left behind the deceit and danger associated with that life and held on to hope that there was something better for me. I’d gripped every hand that reached down to pull me up and out. And no way had I come this far to end up in a fancy version of the hell I’d left behind.

  At the moment, I wasn’t sure what, if anything, I could do. But I knew this: Remaining silent was no longer an option.

  3

  BRICK CITY

  My exhausting twelve-hour shift at Beth was just a minute from ending one day in 2003
when I found myself in the center of a tragic reproductive mystery. The previous night had been a breeze—a few runny noses, a dog bite, and a couple of pediatric ear infections. As I glanced up at the clock one final time, the doors to my left swung open, and my replacement, Dr. Jones, strolled in, looking fresh and ready to take control. All I had left to do was sign out my two remaining patients, one of whom had an upset stomach that I was hydrating with saline and the other a heart patient with chest pains that we were monitoring closely.

  In emergency medicine, the sooner you master the overnight shift, the better. But no matter how many times I worked it, I just never got used to staying up all night. This day was no exception. My brain had reached overdrive, and my red, bleary eyes gave away my exhaustion. I was just about to bid my colleagues good-bye when I heard a commotion brewing to my right. Looking past the tight circle of nurses, technicians, and residents, I managed to make out a woman slouched in a wheelchair being rushed into the department. Her head was flung backward, and her arms hung limply at her sides. She looked pregnant and appeared to be unconscious. Instincts and adrenaline kicked in. Only a few feet separated me from Dr. Jones, who was moving toward us, but in matters of life and death, seconds are crucial. I was closer, so I sped to the patient’s side.

  She appeared to be in her early-to-mid-thirties and about thirty to thirty-five weeks pregnant. As the staff lifted her from the wheelchair onto a stretcher in the resuscitation room, I started my rapid-fire battery of questions.

  “What happened?” I yelled in the frenzy.

  My colleagues chimed in what they’d been able to piece together quickly when they ran to the door after hearing her husband’s frantic pounding on the emergency room window: She’d suddenly started having trouble breathing at home, and as her husband was rushing her to the hospital, she lost consciousness. An emergency room respiratory technician delivered oxygen through a bag valve mask, a lifesaving device used to push air into the lungs. I instructed the junior resident to take over and the senior resident to prepare for intubation, the placement of a breathing tube into the patient’s windpipe or trachea. In search of a pulse, I placed my right hand on her femoral artery, one of the major blood vessels located in the upper thigh—but I felt nothing. I heard no heartbeat through my stethoscope either. There was no chest wall movement, no breathing. I started CPR and yelled for a nurse to page the obstetricians. An E.R. technician pulled a metal footstool to the side of the stretcher, jumped atop it, and started pushing on the patient’s chest, performing compressions as if his own life depended on it. This would help circulate the blood throughout the patient’s body and deliver it to her vital organs—the heart, brain, and kidneys—as well as to the unborn child. We had to get her blood moving; it was our only hope. The wait for the obstetricians seemed to take forever, but they arrived in only about two minutes, panting from their sprint to the emergency department. They recognized the medical emergency right away. Seconds later, they were gloved, scalpels in hand.