fostering the humanistic practice of medicine publishing personal accounts of illness and healing encouraging health care advocacy

fostering the humanistic practice of medicine publishing personal accounts of illness and healing encouraging health care advocacy

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Clean. Dry. Intact.

The bus is crowded today, and January sleet splashes against the windows. The damp of each of us thickens the air. I breathe in a miasma of germs and others’ breath. My scarf wets my face as the snow melts.

An eternity goes by before we reach the downtown stop. From here, I’ll take one more bus to get to the hospital where I work as a physician assistant on a team that treats infections involving blood vessels and the heart. I’m huddled an appropriate distance from the other commuters, my back to the wind.

If we could stand closer, like penguins, we’d be much warmer, I think. Unfortunately, we are not penguins.

I see my second bus pulling up to the stoplight when my phone rings. It’s Victoria, the doctor I’m working with today.

“Are you on the bus?” she asks urgently.

“Not yet,” I say. “Things are running a bit behind. The weather.”

My bus will arrive any minute; I want her to hurry up and tell me whatever she has to say.

“It’s Jessica,” Victoria says rapidly. “She coded last night. She’s dead.”

“Are you serious?” I want to yell. I want to grab another commuter and tell them what’s happened. I want to cry.

Jessica. She’d been with my team since November. She’d immediately stood out to me. Most of our patients were elderly or debilitated; the younger ones were wasting away from addiction and chronic illness. But not Jess. She was vibrant, chatty, animated. She was pretty and polite.

She’d come in with a blood infection that started in her legs. They were rotting from the tranquilizer-laced heroin she’d inject into her veins. The wounds festered, and when she ran out of wound-care supplies the pain grew unbearable, so she would turn again to the heroin, desperately seeking relief.

But the vicious cycle continued. The wounds on her legs deteriorated further, and the infection spread through her blood to her heart. She needed a new heart valve, but first the vascular surgeons had to fix her legs. She went for several debridement surgeries, in which they scraped her necrotic leg wounds until they bled, hoping for the bleeding tissue to keep bleeding, to heal. Finally, near Christmas, they covered her wounds with a mesh made of cadaver skin.

Then something happened: Jess’s heart started to fail. It happened so fast that her falling blood pressure made her liver also start to fail. She had a seizure. Her blood pressure plummeted. She went to the ICU.

We would go talk to her, the infectious-disease physicians and me. Every day. Trying to persuade her to hold on until her heart improved enough to allow the valve replacement.

“Jess, you can get better, okay?” we’d say. “The medicines are helping your heart, and if they help your heart, that will help your liver. They can’t fix your heart valve right now, Jess. If they open you up now, you’ll die. Cross my heart, it’s the truth. I see that they talked to you about saying goodbye to your family, just in case. You have to keep fighting.”

Her eyes would drift open, their whites tinged yellow from the bilirubin in her blood. “I don’t want my kids to see me like this,” she’d say. But she knew it was important to say goodbye, so she promised to think about it.

Before her transfer to the ICU, she had watched Catfish on MTV. She’d sit up in bed, doing her hair and makeup. She glowed from the inside.

“I’m going to get clean,” she would tell me. “No more injecting.” She was leaving her husband, who also did heroin.

“I’m going to make my kids proud.”

She wanted so badly for us to believe her. And we did—most of the time. I’d learned that most patients who are staring down a life-threatening infection will say anything to convince us, and themselves, that they are committed to sobriety. I’d learned to affirm them, encourage them—and not to be surprised when they ended up back in the emergency department with yet another heart-damaging blood infection.

What was Jess hiding behind her bright smile and her optimism? Was she just telling us what we wanted to hear? I wanted so badly to believe her. It wasn’t hard, hearing her say the right things, seeing her brilliant smile.

On one ICU visit, I found her putting on makeup, and I knew that we had a chance. Her liver was still in overdrive, but less so. She looked brighter.

“The surgical team may replace your valve next week,” we all told her. “Your liver just needs to get a little bit better.”

When I returned after Christmas, she had a new valve in the right side of her heart. Her liver-function tests were normal. She was weak, but getting stronger. The line down the center of her chest, where they’d opened her up, was healing well. “Clean, dry, intact,” we described it in our notes.

That was Jess now. Clean. Dry. Intact.

For many of our patients, getting surgery is only half the battle. Afterwards, the road to recovery is long and fraught with risk. Each day, we watched Jess grow stronger, take longer walks in the halls, eat more, see her family more. She was going to make it.

Now, waiting for my second bus, I’m coming off a long weekend. I made so many phone calls last Friday, finalizing the plans for Jess’s discharge today. She was going to a nursing facility for rehab. She was going to finish her antibiotics. She was walking on her own. I cheered her on, knowing that she would soon pass out of my care and into the next chapter of her recovery journey.

I file onto the bus, Victoria’s words ringing in my ears. The humid air smothers me. I want to gag. I start to cry.

Jess was my age: thirty-three.

They found her slumped over, unresponsive in her hospital room chair. A nurse will tell me later that Jess called out for help right before they found her. Those were her last words.

Nearby, they found an empty Xanax bottle—a prescription that her mom had picked up, Jess had said, to help Jess manage her anxiety once she left the hospital.

“You don’t need that much at home,” the addiction team had told Jess. “Have your mom bring it in; we’ll dispose of it.”

That was Friday. Now it’s Tuesday, and she’s supposed to be getting out—alive. Clean. Dry. Intact. Breathing.

There was a syringe in her room, too. With “sediment,” a note said. Sediment of what? Heroin? How could that be possible? Was she injecting into her IV line? And how did the Xanax get into her room? If her mom had brought it, thinking it would be disposed of, did Jess somehow convince her to hand it over? What about Jess’s plans, her recovery? Perhaps, in the end, it had all been too much to face. Or had the new valve sent a fatal clot into her lungs?

Everyone is confused, devastated. “She was so sure she could stay clean…She was so excited to go home…How could this happen?” We look hopelessly at each other, remembering how convinced we’d been that she was okay. And maybe she had been. We can’t ask her now.

Her mom has requested an autopsy. They’ll take Jess again, through a door with a keypad. They’ll lay her out, naked, on a cold metal table. They’ll open her once more. Cut her from head to tail. Take out all of her parts, test her fluids in a lab. They’ll shine a bright light inside her darkest parts. Maybe this time we’ll find the sickness.

Maybe this time we’ll see what she was hiding from us all along.

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Rebecca Haddad is an infectious-disease physician assistant at the University of Pittsburgh Medical Center, specializing in endocarditis and other cardiac infections. “Throughout my life I have used writing to process the often nonsensical occurrences that accompany human existence. In committing words to a page, I have been able to see a way through the pain and to remain connected with the beauty, love and joy that can be found in life.”

Comments

11 thoughts on “Clean. Dry. Intact.”

  1. Karen A Thompson, LMSW

    Thank you for this story. It reminds me of my work in the ‘80’s as a hospital social worker. Addiction is a disease that is unrelenting.

  2. Thanks for sharing your heartbreaking story. It reminded me of my 3rd and 4th yr med student heartbreaking patient outcomes with similar patients. Sad story – nothing has changed. Addiction is a terrible disease.

    1. Such a sad story, as well as a powerful reminder that “willpower” and the desire to be healthier are not cures for the disease of addiction.

  3. Louis Verardo, MD, FAAFP

    Addictions are the most difficult conditions for patients to overcome and for clinicians to treat. You and your colleagues did all that is humanly possible to assist this patient in recovery; perhaps the patient did her best as well, although that part may never be completely understood.

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