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Found Down

I keep having this dream where I’m trying to call 911, and I can’t. I can’t seem to get the phone to work. I become panicked, and I can’t breathe. My heartbeat pounds in my ears, and I feel the sharp taste of bile in my throat.

When I wake up, that shaky feeling of fear and impotence clings to me. I don’t ever remember what was wrong in the dream–why I needed to call 911. I just remember not being able to.

Lately, that feeling has been haunting me during my waking hours, too.

Over the past couple of months, as I drive through town, I keep seeing people who are “down.” “Down” is a term used in medicine for someone who is discovered unconscious, typically in a non-hospital setting–as in: “Patient was found down.”

Nothing good ever comes from being “found down.”

Each of the people I passed who were “down” already had help present or on the way. But the thought of having to be that help terrifies me a little. Even with all of my medical training, there’s not a ton I can do for someone “found down” in the field, besides call 911. These people need more help than one lone individual on the street can provide, even if that person is a physician.

A couple of phrases typically accompany the words “found down” in a medical chart: “polysubstance abuse” and “history of noncompliance.”

Taken together, those three phrases paint a particular picture for a medical professional. This picture ain’t pretty.

It’s the picture of modern addiction in America.

It’s heroin and fentanyl and carfentanyl and meth and bath salts and ecstasy and Dilaudid and oxys and roxys and crack and cocaine and krokodil.

Part of the reason this scares me so much is that, like my Mama says, “We’re all one car accident away from opiate addiction.”

These people who are found down could be you or me or any of us.

Pain medication is incredibly addictive.

Say you get in a fender bender and break your ankle. Say you’re unlucky, and you need major reconstructive surgery. Maybe you’re really unlucky and need a couple of surgeries to get your ankle working as good as new.

Every time you have a surgery, we give you opiates in the hospital, and we send you home with some, too. Your ankle hurts. Your pain is real. You take the medications prescribed by your doctor. And those pain medicines work!

The problem is opiates literally light up the pleasure pathways in your brain. With continued use, your body comes to rely on them for rewarding feelings, and to dull pain–physical, emotional or existential. Over time, this can lead to addiction.

In the hospital, we “save” the people that helpful bystanders like me or you have “found down.”

We detox them. We help them breathe with tubes and ventilators. We put them on dialysis to clean their blood. We give them the big-gun antibiotics to kill the bacteria in their blood. We replace their infected heart valves and clean out their infected joints.

We save them–but we don’t, really. And we know this.

We have the tools to help with their addictions–medications, therapy, rehabilitation centers–but these all take time and money, which the healthcare system can’t or won’t commit to this problem. We know the solutions; we just can’t get people the help they need. Treatment cost and lack of access to treatment are barriers to care–barriers that most patients cannot overcome.

These patients always come back. And the next time, or the time after that, we may not be able to save them.

In 2017, there were more than 70,000 drug-overdose deaths in the US–an increase of almost 10 percent over the year before.

That works out to 192 overdose deaths a day.

The increase in injection-drug usage has also brought a rise in things like hepatitis, syphilis and HIV–illnesses that, in a healthy, well-resourced person, a person with social support, access to care and financial reserves, are either curable or very treatable. But the people most at risk of overdose are not likely to be healthy or well-resourced.

We are in a state of crisis.

In the ICU, I recently cared for a man who had overdosed. We’ll call him Jim.

Jim, a man in his late 20s, was found down in the field and had multiple prior admissions for similar issues. His chart was peppered with phrases like “polysubstance abuse” and “medical noncompliance.”

Jim’s parents and sister faithfully showed up to visit every day. They cried over his bedside. They held his hand. They beseeched God to deliver a miracle. They were distraught, but they weren’t shocked by the situation. They had been in other ICUs before. They had visited him in rehab and cared for him at home each time he relapsed.

He required sedation, intubation and mechanical ventilation, dialysis, drugs to keep his blood pressure up, antibiotics and consultations from specialists in cardiology, nephrology, neurology and neurosurgery. On top of his overdose and subsequent cardiac arrest, he had diagnoses of untreated HIV and hepatitis C; while he was in the ICU, he was also diagnosed with syphilis.

In the days following Jim’s admission, we provided every intervention that modern medicine could offer. We did everything we could–and it still wasn’t enough.

Jim didn’t make it. We did not save him. I can tell you that the whole care team–the attending physician, the nurses, the techs, the consultants, everyone involved–felt just as scared and impotent as I did.

In another life, Jim would have been any other healthy twenty-something. He might have been your plumber, your little sister’s boyfriend or even the nurse taking care of your loved one in the hospital.

I think that’s why deaths like his feel like such a failure. Because even though we can see the root cause–the addiction–that leads people like Jim down this unimaginably horrible path, we still don’t have a working solution. We’re like the little Dutch boy with his finger in the dyke. We feel the tide rising against us, and all we have to fight it is stop-gap measures.

I’m tired of stop-gap measures. I’m tired of treating the same patients over and over and not actually helping any of them.

The opiate crisis is a plague that is ravaging our country. And for now, I guess, it will continue to haunt my dreams.

Caitlin Bass is completing a fellowship in hospice and palliative medicine at Sarasota Memorial Hospital, FL. She loves writing, and she loves medicine. She writes about life and laughter and medicine on healthclasswithdrbass.blogspot.com. Her work has appeared in Pulse, KevinMD, The Physician Moms Group and The Washington Post. “In the time since I wrote this piece, I actually did find someone ‘down’ one evening when I was out walking my dog. At first, all I saw were her sandaled feet with brightly painted toenails, sticking out of the bushes onto the sidewalk. I was able to successfully call for help, and I no longer dream about dialing 911. But I don’t think I’ll ever be able to get the memory of her painted toenails among the shrubbery from my mind.”


3 thoughts on “Found Down”

  1. Heartbreaking and terrifying epidemic – truly an abdication of our health care system from creating a systematic, caring approach to a public health emergency.
    Perhaps it’s time to equip our public – and health care professionals – with Narcan to carry around with us to treat those found down in our communities. Then we don’t need to wait for 911 to save us – Narcan empowers us to save others.
    I prescribe it for all my patients with opioid use disorder, and carry it around in my backpack too – haven’t needed to use it in public yet, but it is good to know that it is there!

    1. Yes, naloxone in the glove compartment.
      Are you prescribing buprenorphine? It feels good to be contributing to changing that trajectory of addiction you describe well.
      Bup works for patients and for doctors

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