Cracked: Putting Broken Lives Together Again - Drew Pinsky, Todd Gold (2004)
RICHARD NORTON WAS taken to the hospital during the night. His wife, Beverly, left a message with my service in the early morning hours. When I call a few hours later she sounds confused and unsure about the details, though with one sentence she tells me everything I need: The attending cardiologist has recommended no further treatment than necessary to keep him comfortable.
“You know him so well,” she says. “We’ve been with you so long. I wanted to be sure you agreed.”
For a moment I fantasize about a transplant operation or other desperate measures, but all are ridiculous in a man of Richard’s age. No, all the right things are being done.
“It sounds appropriate,” I say. “Please keep me informed. I’ll check in, too. Let me know how you’re doing.”
“Our children are with me,” she says. “We’re okay.”
I spend the short drive to the unit thinking about Richard. He was a warm old man who would come in for an ache or a checkup and leave having made me feel better. We spent a lot of time over the years talking about his career selling scrap metal around the world, in places that provided him with great stories made even better by his gift for gab. But the thing I remember most about Richard is his passion for his family. Though he made a nice living, I can still hear him saying that money never bought him the things that gave him pleasure: his children and friends.
“What do you do with your kids?” he once asked me.
“I play with them,” I said. “I help with homework. I coach sports. I go to my daughter’s skating competitions.”
“Good,” he said. “We spent a whole lot of time just talking with our children. I think those were the best times of my life.”
“I understand,” I’d say.
“That’s wonderful,” he said. “Most people your age don’t have a clue.”
Neither do I have a clue about the source of the noise I hear when walking into the unit. It turns out to be a soda can bouncing off a wall, which I spot when it rolls out of Room 120. A counselor passing by at the same moment glances at the room and shakes her head, warning me it isn’t pretty inside. I trod in warily and remind the patient, Titus Fenton, a medium-built black man with long dreadlocks and thrift-store clothes, that neither his room, the hallway, nor anyplace else in the unit is a trash can. He couldn’t care less.
The man looks fifty-two; his chart says he’s twenty years younger. That’s startling, but not nearly as much as the condition of his room. He has occupied it for not quite three and a half hours, and yet it is layered with clothes, papers, blankets, sheets, and food wrappers. It is a pit. He has also managed to estrange himself from the staff.
“So what’s up?” I ask. “Why are you here?”
“I’m strung out,” he mutters. “I’m a junkie. My girlfriend made me come.”
“Congratulations,” I say, already turned off.
“I’ll be leaving in two days,” he declares. “I’m out of sick days at work. I need the dough. That’s my survival, man.”
Titus is snappish, rude, scattered, and not aware that his life isn’t working for him. All that aside, though, it’s hard to like this guy. It’s bad chemistry. I’ll make sure he’s getting the best treatment we can offer. But I’m not going to waste my efforts trying to make a connection. It won’t happen, no matter what. When someone like Titus declares that he’s history, with this kind of strong conviction, I have no reason to doubt him.
We get a number of patients like Titus. It’s part of the disease. They pass in and out, literally and figuratively. They usually aren’t nasty to anyone, though; Titus is an exception. Nor do they pose any particular threat, other than stirring up the other patients, as long as they don’t bring drugs onto the unit. I am just looking for the smallest shred of desire to get better. He doesn’t care about the rules I lay out, because he doesn’t intend to deal with them. He has his own game plan. He hasn’t figured out that it’s a losing proposition.
Titus isn’t close to being ready for recovery, but I suspect something else is going on here. He has another agenda aside from recovery. Sometimes we find out later that patients like Titus are using us to hide out from some more immediate threat: the law, process servers, dealers, gambling debts, or their family. Still, as long as Titus doesn’t create any major problems on the floor, he can stay. Sometimes all it takes is planting that seed of recovery.
But there are better uses for my time—like my next patient. A single mother of a ten-year-old girl, Hannah is a twenty-eight-year-old from South Pasadena. I suspect I’ve seen her around, but she says no; then I ask about the Pasadena City College T-shirt she’s wearing, and learn that she grew up close to my childhood stomping grounds. Her story also has a familiar ring. She began taking Vicodin after getting a tooth pulled, and it triggered a predisposition that soon became a three-year opiate and benzodiazepine addiction. She tried to kill herself two days ago by overdosing on Ambien, Vicodin, and Xanax. She transferred last night from a nearby emergency room. She’s sitting up in bed when I see her, frantically rubbing her arms.
“I feel like I’m climbing out of my skin,” she says.
One look and I can see why. Her hands shake involuntarily. Though she doesn’t go into the excruciating details, I know she is battling the sensation of a constant, painful sizzle of nerve endings. It’s the manifestation of her central nervous system firing up after months of being suppressed by downers. It’s as if she’s frying from within.
“I’m so depressed. I can’t believe what I did,” she says in a whim-pery voice.
“Tell me what you mean.”
“What I did to my daughter when I tried to kill myself.”
I take a seat next to her bed. She went to college, she tells me. She wants it known that she’s not a tramp. She reads, she says, gesturing to a pile of novels on her nightstand. But living with an addiction, she gradually lost her friends, then her job, and she figured the rest of her life was next. A stint on welfare was followed by a struggle for survival. After deciding she couldn’t go on any longer, she decided in a fit of desperation and depression to take her life, and enlisted her daughter’s help by having her bring more and more pills from the medicine cabinet, swallowing two at a time until the bottles were empty.
“She kept asking if I was okay,” she says. “She thought I was taking too much. But I insisted I was sick, and the doctor told me to do it. I lied.” She breaks into tears. “God is going to send me to hell for lying to her like that. Then I told her—her name is Cheryl—to go do her homework and put herself to bed if Mommy fell asleep before her. God, how awful is that? How much did I screw up? How much is my baby going to hate me? I hate myself.”
I don’t move or say a word. The best thing I can do for her at the moment is to just be there for a few moments so she doesn’t feel alone.
“I want you to go to group this afternoon,” I say.
“My family is coming tonight,” she says. “Should my daughter come, too?”
“Yes,” I say. “And get her in Alateen.”
I can also hear Finley jumping on me to get the girl a therapist. Hopefully there will be insurance resources for such care. No way Hannah can pay herself.
“How long will I be detoxing?”
“Five to seven days.”
“Then the shaking will stop?”
“There’s no more medication, right? I mean, they’ve given me something. But I can’t have anything for the pain, right?”
As I turn to leave, she stops me with a slight tug on my elbow. She sits up, takes a tissue from the nightstand, wipes her eyes, and then blows her nose.
“Dr. Pinsky,” she starts, but then nothing comes out for a few minutes. During the silence, I pull a chair next to the bed and sit down, content to wait. When I think about all the medicine I’ve practiced over the years, the most useful skill I’ve managed to develop is patience. A large portion of my job is spent listening to people.
“Dr. Pinsky,” she continues. “I’m really, really…really…scared. I don’t want to die.” She is overcome by tears and needs another moment to regroup before speaking again. “I didn’t want to kill myself. But I couldn’t take it any longer. I just hate feeling this way. It’s ruined my life. I’m so fucked up.”
I stand by her bed in silence. I try to express my appreciation of her pain with my expressions. It’s hard not to be overcome and invaded by her feelings. My impulse is to rush in and rescue her from her discomfort. I could just medicate it away. But no, my job is just to remain present and reflect my understanding of her distress. This is how she will develop a road map of her emotions, and the capacity to regulate them. And that will reduce her risk of using. I want her to know there are people she can trust not to hurt or exploit her, starting with me.
“We’re here to help,” I say. “You can trust us. We’ll help get you through this.”
When I finally return to the nursing station, Alexi hands me a message from my private practice nurse, Angel. It says to call the office. But Alexi delivers the news: My patient Richard has died. For a moment, both of us just look at each other in silence. She knows I’ll need a moment to digest the information.
I never thought much about death growing up, and then when I was exposed to it in medical school it was very clinical. Without any kind of personal investment, I couldn’t think about it beyond the way I felt about death myself, which has evolved over time. My attitude is matter-of-fact, pragmatic: It’s better to be alive than dead, and while you’re alive, you should try your best to make the experience rich and meaningful. At the end, you want to be flooded with good memories, with thanks for the people you love and the time you’ve shared with them. Just as no one ever died wishing they’d spent more time at the office, no one ever died saying, I wish I’d spent more time by myself.
Which makes Richard’s story, in the end, a happy one. I hated to hear about his death, but there was something dignified and right about it. He was a great guy, a loving husband, father, grandfather, and friend. Through all those close to him, his life would continue to have meaning. Occasionally I’m asked what, if anything, I know about death beyond the clinical. I usually say there’s a lot to learn about death from people who are dying, but in the end they really teach us the value of living, and that’s where I place my attention.
I’m not alone. The will to live is instinctual in humans. The will to feel good and exist without pain is just as strong. I see it even in my worst patients. In fact, on my way out I stop by Amber’s room. Our eyes connect for a second, and I see terror flash in hers. As soon as I’m in her room, she lets me know she’s in pain.
“I need something more to take me down,” she says.
It’s hard to resist Amber’s plea. Something about this young woman is undeniably attractive, not just to me but to a number of us in the unit. She’s settled into the routine with some success lately, though she’s still regularly overcome by waves of agitation and a periodic desire to bolt. This is clearly one of those moments. “I need to be here,” she says. “I feel like I want to use. If I go home, I’ll use. I will, I swear to God. And it’s freaking me out.”
I nod, and try to stay with her emotionally. The dynamics of situations like these are intense. Recovery takes months and years of self-help and frequently some psychotherapy, but in this initial phase of treatment, when the goal is getting the patient safely through her unstable medical and psychiatric problems, evaluating her needs, and getting her on track, a single moment can start the turnaround.
I don’t think Amber is there yet. She’s caught in the struggle of wanting to live and knowing she might die if she makes the wrong choice. As a doctor, I’m trained to help. But sometimes I can’t do anything more than be there and offer support. It’s a strange situation: She’s struggling to find the strength to fight her addiction, and I know that better than she does, but ultimately there’s only so much I can do to help. In the end, she has to summon the strength and do it herself.
“Can’t you give me something?” she pleads.
“I’m doing everything that’s right for you.”
And so the day ends, patient and doctor together.
Neither with the answer.