Living and Dying in Brick City (4 page)

W
hen I arrived at Beth Israel in the summer of 1999, eager to do something about the suffering all around me, I was already long familiar with the ways of crack addicts and street junkies. I’d marveled at their lies and their never-ending hustles. I’d seen their love for family, friends, and even God take a backseat to a new god, that white rock or powder, even if all the while they hated themselves for it. Little about that world surprised me anymore. But I was soon introduced to another world, a hidden drug culture right under my nose.

That summer, my first sickle-cell anemia patient showed up in the emergency department during one of my shifts at Beth. He was twenty-three, complaining of pain in his shoulders and upper back. I got excited—in the macabre kind of way that happens when a doctor is about to learn firsthand about an illness or injury he has seen only in textbooks.

Sickle-cell anemia is an inherited blood disorder that in the United States primarily affects African Americans. In a normal patient, red blood cells are oval-shaped, which is optimal for carrying oxygen and allowing blood to flow easily through arteries and veins to the organs and limbs. But a sickle-cell patient has abnormally shaped cells that look like a crescent or sickle. The
deformed cells sometimes clump together, blocking the regular flow of blood and oxygen and causing excruciating pain in the deprived areas.

During medical school I studied the disease intensively, since I already knew I wanted to work in an urban hospital, and I figured the illness would show itself time and time again. So on that summer day, I knew all about the illness, but I’d never met anyone with it.

My patient looked like a skinnier version of the actor Wesley Snipes, with dark brown skin, a high-top fade cut close on the sides and back, baggy jeans, and a pair of tan boots. He was writhing on the stretcher.

“Doc, I’m in so much pain,” he cried. “I feel like I’m about to die!”

He asked for ten milligrams of Dilaudid, a semi-synthetic version of morphine that is far more potent. Ten milligrams of Dilaudid would have the same effect as about seventy-two milligrams of morphine. That much of such a powerful drug could kill the uninitiated, but to a person in chronic pain who has built up a tolerance for it, the high dosage just brings quick relief. I didn’t doubt for a moment that my patient needed it. At his age, he surely had experienced more than a few episodes of sickle-cell pain, which explained in my mind his certainty about the medication and dosage he needed. A quick glance at his chart showed that he’d been given ten milligrams of Dilaudid during his last E.R. visit.

I jumped into rescue mode, assuring the brother that I would take care of him and get him started on the Dilaudid, as well as an oxygen treatment, intravenous fluids, and the Benadryl he’d requested to soothe the itching often caused by histamines released with the medication. I rushed down the hall, found the attending physician, and immediately started describing my patient.

“I have a twenty-three-year-old sickle-cell anemia patient presenting
with pain in his shoulder and upper back,” I said, full of urgency and earnestness. I mentioned the treatment I wanted to prescribe, in the hope that the attending would sign off quickly. The head doctor’s cavalier attitude caught me off guard.

“Oh, that’s Thomas Green,” he said, chuckling.

His face wore an inexplicable smirk.

“My young doctor,” he added, patting me on the back, “you have so much to learn.”

I was puzzled. Had I missed something in the diagnosis? The head doctor assured me that this was the right course of treatment for a patient whose pain hadn’t responded to lower dosages of the medication or weaker drugs. He approved my recommendation and walked away. Still, his initial response nagged at me. What had his smirk been about? I checked Thomas’s chart again, this time more carefully. Sure enough, he’d been given ten milligrams of Dilaudid during his last emergency room visit—as a matter of fact, during his last several visits. I slowed down, looking closely at their dates, and my jaw dropped. Thomas had shown up at the hospital in crisis at least fifteen times in the past month. Even for a sickle-cell anemia patient, that was excessive. No wonder the attending physician knew immediately who he was. And no wonder my supervisor found my sincerity laughable. This dude seemed to be running a game.

But how could I be sure?

Therein lies the doctor’s dilemma. We can diagnose illness, and we can identify the conditions that generally cause pain. But we cannot quantify pain. Medical professionals have long defined it in the same way registered nurse and pain management expert Margo McCaffery described it in 1968: Pain is “whatever the experiencing person says it is, existing whenever and wherever the person says it does.”

So now, despite my suspicions, I could not say with 100 percent
certainty that Thomas was faking in order to get the drugs. I could have costly tests run to show there were no other ailments, but that wouldn’t prove there was no pain. Sometimes, even when we’ve done every test known to science, and they show no reason for pain to exist, it still does. Much of medicine remains mysterious; new discoveries are made every day. As a physician, I never want to see anyone suffer. My fulfillment comes in healing and easing pain and suffering. The last thing I want to do is make an unfounded accusation against someone who is genuinely suffering. There was another issue that concerned me, too: race and stereotyping. Thomas was African American, and I didn’t want to assume that he was lying to get a fix. As an African American man, I know what it’s like to walk into a room and feel the vibes of people who are making assumptions before they know the first thing about you.

I stood there reading his chart and reasoning. Thomas had a genuine disease, a painful disease, and I saw he had suffered mightily. Diminished blood flow to his hip tissues and bone had caused a degenerative condition called “avascular necrosis,” which had required him to undergo hip replacement surgery. His spleen had been removed after a buildup of sickled cells had caused a splenic sequestration—an enlarged spleen. And Thomas certainly appeared to be in pain now as he lay curled up on the stretcher. His chart indicated not only his tolerance for the drug but the decision many doctors before me had made to give it to him. So I followed suit and administered the Dilaudid.

About two hours later, making my way through the unit where Thomas had been assigned, I saw him sleeping soundly. Walking down the hallway, I accidentally bumped into his stretcher, which was pushed against a wall. He jolted straight up, looked at the clock, and said, “Hey, Doc, glad you’re here. I need more pain medicine.”

Beth Israel had a rule: Dilaudid and other narcotics of that type could be administered no more than once every two hours, and ten milligrams was the maximum dose that doctors were allowed to prescribe in the E.R. Thomas had awakened from a sound sleep already needing more pain medicine? He’d timed his request almost to the minute. With a string of emergencies vying for my time, I couldn’t stand there debating whether this guy was in real pain or playing me for a fool. “I’ll send a nurse to help you,” I said, dashing off to the next patient. Thomas would request a third dose, the maximum allowed without being admitted, before suddenly feeling well enough to go home. The attending physician’s words echoed in my head:
My young doctor, you have so much to learn
.

So began my education into the underworld of the E.R. Thomas showed up at the emergency department at least twice a week, same routine. What little faith I had in his sincerity began to fade, especially as I noticed the same suspicious behavior among about a half-dozen other patients, whom I came to know as the “sickle-cell posse.”

A
nn and LaShawn were friends in their mid-twenties who probably had met in Beth Israel’s emergency department. When one would show up, claiming to be experiencing the worst pain of her life, the staff came to expect that within a half hour, the other would make her way there as well. Ann, short and slim, would stroll in, usually dressed in jeans, a T-shirt, and sneakers. She had a long, reddish-colored weave flowing down her back. And less than thirty minutes later, on cue, there was LaShawn, also short and thin, with gold streaks in dark hair that she kept mostly hidden under a baseball cap. They always asked to be assigned beds next to each other, and they’d bring nail polish and other beauty products to share. Since they were there for six hours or more at a
time, they’d traipse up and down the hall to the vending machines, buying chips and sodas. As I passed them, I’d see the two sitting on one bed, their supplies spread out between them, giving each other manicures and pedicures, or braiding each other’s hair, like they were on summer vacation. Or they’d just sit there, chatting, dangling their legs, talking on their cell phones, and watching the clock.

Precisely two hours after getting their first meds, they’d raise their hands, like they were in school. “Doc, I’m due for my second round of pain medicine,” one of them would state, as if the next dose was supposed to be automatic. And after their third dose, they would say they were better and ready to go home. Hospital rules required me to admit a patient who showed no progress after the third dose. None of the so-called “frequent fliers” wanted to be admitted. Overnight stays in the hospital meant more regular monitoring and lower dosages of the narcotics over longer periods, and it completely cramped their itinerant style.

The gall of their assumptions angered me. I thought,
You’re not automatically due for a second round of drugs; you’re allowed a second round
if you’re in pain.
And how much pain can you be in right now, painting toenails?

One day, a nurse who doubled at other hospitals was working her shift at Beth Israel when she recognized the pair of friends and exclaimed, “Oh my God, that’s Ann and LaShawn—I just saw them yesterday at University Hospital!”

It came as no surprise to anyone that the two women E.R.-shopped, visiting emergency rooms throughout the area to get drugs. An addict will go wherever and whenever to get her next fix. The drugs are also quite valuable on the street, and so a prescription could be a moneymaker.

T
he hospital tried mightily to help patients with chronic pain, and, of course, those who abused narcotics represented just a small portion of the ones treated for pain in the emergency department. And let me be clear: Not all sickle-cell patients are drug seekers. Likewise, not all drug seekers are sickle-cell patients. During practically every shift at least one patient came into the E.R. complaining of severe back pain, a toothache, a migraine, or some mysterious pain and offering a story that raised suspicions: His regular doctor was out of town, or her medicine was misplaced, or he was vacationing in the area and had left his medication at home. They usually asked for the narcotics by name: Dilaudid, morphine, OxyContin, Percocet were among the more popular ones.

Sometimes they even put on Oscar-worthy performances, like the guy who was brought by ambulance one day from the Newark train station. He was supposedly traveling back home to Massachusetts from Texas, and while on a layover in Newark he experienced what witnesses described as a seizure. He reported to our staff a past history of chronic back pain but no prior seizures. While being observed and awaiting the results of blood work, the patient again began convulsing. The resident on duty moved fast to administer medication, likely Ativan, to control the seizure. I rushed to the patient’s bedside. For several minutes, his body shook. But one thing stood out: He never let go of the bed’s handrail. Normally, a person having a grand mal seizure loses total body control and is incapable of holding or grasping anything. I opened his eyelids, and his eyes followed me. I knew exactly what was going on. I leaned over and whispered in his ear, “Stop it, I know you’re faking.” He didn’t respond.

It was rarely that easy to determine when a patient was just seeking drugs, though. Among the “frequent fliers,” having a documentable disease made the hustle easier. And it soon became clear to me that prescription drug abuse, once the nasty little secret
of the rich and famous, was now a huge twenty-first-century problem in urban neighborhoods. These new addicts weren’t hiding out in abandoned houses, shooting up behind closed doors; their drugs of choice were administered by professionals in the cool, clean corridors of the E.R. And the unwitting dealers in this game weren’t working the streets with Glocks hidden in their pants, they had fancy degrees and wore white lab coats. That’s what bothered me the most: I started to feel like a high-class drug dealer.

When I mentioned to Ann and LaShawn that they’d been spotted in the emergency room at University Hospital the previous day, neither seemed fazed. Both said something like, “I was in pain, and University was close to where I was.”

So I treated them. I felt I had no choice. Number one, I didn’t want to take the risk of failing to treat a patient who was really in pain. State law requires that I provide medical care to everyone who comes to the hospital seeking it, and I couldn’t prove that these patients were
not
in pain. The hospital staff lived with the constant fear that a patient would complain to the state about being denied treatment, which could trigger an investigation and result in the hospital getting cited and potentially facing cuts to its Medicare/Medicaid funding. With dwindling resources forcing hospitals throughout the country to close their emergency rooms or shut down altogether, the threat felt very real. It was easier just to write the prescription.