24 hours in the life of an opioid epidemic

As seen by medical students at Temple’s Episcopal Campus

An estimated 50,000 to 75,000 Philadelphians struggle with opioid use disorder and each day thousands come to one neighborhood, Kensington, to buy their drugs. Hundreds live there as homeless.

In October, the mayor declared a disaster in the neighborhood. The federal DEA has called heroin sales there “the biggest open air drug market on the East Coast.”

Central to the medical response is the Episcopal Campus of Temple University Hospital.

“Episcopal is absolutely ground zero,” said Dr. Thomas Farley, the city’s health commissioner.

Staff at Episcopal treat as many as 80 overdoses a week, according to Joseph D’Orazio, an emergency room doctor and head of addiction medicine for Temple. An accurate count is difficult, he says, because many who are revived don’t hang around long enough to be counted or identified.

The idea for this project was to give first and second year medical students — who spend most of their time still in the classroom — the opportunity to learn about drug use and to see an epidemic up close, in real time.

Equally important, the students would write and reflect on their experiences, chronicling 24 hours in the life of the opioid epidemic at Episcopal.

In preparation, students attended lectures on addiction medicine and the history of drug use in Kensington.

Starting before 7 a.m. one winter day, and ending after 6 a.m. the next, 22 medical students came to the hospital — one each hour. Every student was assigned to a doctor in the Emergency Department, or in the psychiatric Crisis Response Center, or on the hospital’s inpatient floors. They were then free to follow their instincts and interests. Some stayed for hours.

Dr. Naomi Rosenberg, an ER doctor who worked that day, and Michael Vitez, Director of Narrative Medicine at Temple, also filed reports — so 24 reports over 24 hours.

Students described their perspective of what addiction looks and seems to feel like for both patients and staff. They also filtered the experience through the prism of being young medical students, seeing such things for the first time.

Out of respect for privacy, identifying details of patients have been omitted or changed. Students wrote in their own styles, lending to 24 different pieces of writing, edited for length and sewn together as a single 24-hour narrative.

These students at the Lewis Katz School of Medicine at Temple University participated in this project and wrote the reflections that follow:

Katya F. Ahr, Angela Battaglia, Anthony Bernick, Roshni Bhat, Joe Corcoran, Phil Delrosario, Amanda Foote, Pablo Gutierrez, Connor Hartzell, Miranda Haslam, Neena Kashyap, Kurt Koehler, John Lasky, Caroline MacGillivray, Kelsey Muir, Katherine Ortmeyer, Will Schifeling, Vered Schwell, Aron Stark, Eileen Storey, Ambuj Suri, and Daniel Yusupov.

Here are their stories.

6:52 A.M.

As I arrive, the sun is just beginning to rise, silhouetting the spires of the hospital’s castle-like tower, beautiful against the pink and orange sky. When this tower was built a century ago, it symbolized the lofty ambitions of medicine, and the dreams of what was then a thriving part of the city. But today, I am struck by how it looks out of place, almost surreal.

I walk into the Emergency Department and shortly after a patient arrives.

Medics found him after a passerby called 911, picked him up off the street, covered in his own vomit.

The doctor looks in his pockets. No wallet. No ID. A small, clear plastic bag peeks out of the front pocket of his jeans.

I’m not sure what I thought heroin looked like. The small bag seems somehow underwhelming.

His breathing is agonal — slow, labored. The medical assistants start carefully removing his clothes. He wears seemingly endless layers of sweatshirts over shirts.

The doctor believes the patient has overdosed and orders a nurse to give him Narcan. When he wakes, he is agitated. So she orders a benzodiazepine to calm him. Soon he rests peacefully.

A nurse comes in to pick up his clothes, piled in a corner, using only the tips of finger and thumb, an unpleasant part of her job, judging by the grimace on her face. She places each item in the white plastic bag used to hold patient belongings.

“His other shoe?” she asks, picking up the single white sneaker.

“He just had the one,” the doctor replies, as if perfectly normal. I wonder what will happen when it’s time for him to leave. Will he be sent back to the streets with his single white sneaker?

After the nurses and support staff leave, the room finally quiet, the doctor crouches by the head of the bed. I kneel behind her.

“What’s your name?” she asks. “How old are you?”

There is no answer.

In the same quiet tone, she asks, “How long have you been using drugs?”

Still no answer.

“Have you been using drugs your whole adult life?”

Finally, a slight nod.

She pauses. Allowing his first semblance of an answer to ring silently in the air.

“Have you ever been able to stop?”

He shakes his head.

“What is the longest you’ve been able to stop for?” she presses.

No response.

“Have you been able to stop for a day?”

He shakes his head, no.

“Do you have somewhere to live?”

A pause. No response.

“Where have you been sleeping, on the streets?”

A nod.

I realize that he’s started to cry only when the doctor reaches her hand to gently wipe under his eyes.

8:06 A.M.

My life in medical school revolves around imposter syndrome. I feel the need to prove that I belong. It seems like everything has become a competition among my classmates to score the highest and achieve the most. By participating in this project, I hoped to hear someone’s story and produce something impressive. It would prove that I am smart and talented enough to compete with my peers.

So, as I walk into the Crisis Response Center (CRC) — where 13,000 people with mental illness and often substance use issues come “in crisis” every year — I am struck by the total calm. A few people in the waiting room are wrapped in blankets, many are sleeping. I wonder, “How am I going to experience something life-changing when all the patients are asleep?”

The resident and I see our first patient, a man bent over, almost to 90 degrees, as he shuffles into the interview room.

“I need help. Please doc, please help me,” the man says, head down, shaking. “I can’t be out there anymore.”

My heart hurts for this man. It is cold outside. He is by himself in a crisis center in an area of Philadelphia the mayor has declared a disaster.

“How are you feeling right now,” asks the resident.

“I feel like I am dying. I don’t want to feel like this anymore.”

I wonder what it feels like to die. I wonder if dying looks like the man in front of me. I wonder what I would do in his situation. The resident asks a few more questions about his drug use and past medical history. Then he moves on to a set of final questions that he asks every patient.

“Can you tell me your name?” The patient answers.

“Can you tell me what city we are in?” The patient answers.

“Can you tell me what month it is?” We wait in silence. “I can’t.”

He is crying now, and I wish I could cry with him. If I could, I would take out a small part of my heart and give it to him to keep him warm and safe. His blanket wrapped so tightly around his frail body is not enough.

We see more patients, and for the next three hours, I forget about the grades that define my life, and I focus on the patients that I hope to someday treat.

I realize that I am losing grasp of the part of myself that wanted to go to medical school. The first two years are important; there is no substitution for having a solid understanding of basic anatomy and physiology. But, by defining myself solely by numbers, I risk losing the piece of myself that yearns to help others. The piece of myself that wants to ask, “How did you get here, what are your dreams, who do you love?”

So as I left the hospital later that morning, I was reminded that I deserve to be here to write my own story. And that is enough.

9:13 A.M.

A bearded man is trying to pry open the automatic sliding door of the Emergency Department and leave. A group of paramedics stand by the door talking about the Eagles. They don’t seem surprised in the least by his attempt to leave, and their leader makes sure nobody swipes a badge to let him out until a staff member can talk to him. A doctor tries to convince the man, who was brought in after an overdose, to stay and, if not to stay, to wait so she can print papers for him to sign before he leaves. A nurse needs information to find him in the medical records.

“Sir, have you been here before?”

“Yeah.”

“What’s your social?”

“Y’all are asking too many questions.”

The bearded man runs across the Emergency Department and exits through another door. Nobody follows him.

One of the paramedics tells me that since Narcan has become widely available, many patients who overdose on the street are given doses by passers-by before the ambulance arrives. By this point, he says, “100% of them get robbed too.” Many, the medic tells me, do not want to go to the hospital. Once physically stable, their first priority, he says, is often tracking down their belongings.

“Lots of folks are really polite when they wake up though,” the paramedic tells me. “We have ‘frequent flyers.’ We honk at them when we drive by.”

Not 30 minutes later, the bearded man comes back and finds a bed in the hallway to take a nap. He says he left the hospital to get some heroin on Somerset Ave. He seems to be feeling much better now. I’m impressed that he was able to leave, purchase heroin, get high and return, all so quickly. The doctors don’t seem surprised.

10:02 A.M.

Steve was a shaggy-bearded young man with blue eyes, in a faded hospital gown and mismatched socks. He seemed surprised at the invitation to a conversation about his heroin use.

He started with marijuana when he was 12 years old, progressing to cocaine and opiates by 18. He currently uses heroin and fentanyl. I found Steve to be open and talkative.

He was homeless, depressed, and infected with both HIV and hepatitis C. He had been hospitalized numerous times for complications resulting from IV drug use. He had been suicidal since childhood. “I never asked for life,” he told me plainly, “and I’ve never felt I had anything to live for. Drugs are what give me gratification.” His father was suicidal and had drinking problems. Steve attributed his own depression and suicidality to a combination of nature and nurture.

His dream was to work on a farm and grow gourmet mushrooms. He had tried quitting drugs, but relapsed after short periods. Could he avoid opioids after leaving the hospital this time? “I don’t have much faith in myself,” he said.

Withdrawal was the worst part, he said. “Your body shakes and hurts and you puke. It’s so bad that you just want to kill yourself. And worst of all, there’s also this magical drug that will make it go away.”

What struck me about Steve was his lack of agency in being able to confront his life’s challenges. It seemed like everything was just happening to him and he felt powerless to change any of it.

When I asked him what qualities he looked for in physicians, Steve said that bedside manner mattered most, along with being a “knowledgeable doctor who knows what he’s doing.” I told Steve I would take his advice to heart and I will.

11: 20 A.M.

The patient had collapsed on the sidewalk, clutching a bottle of vodka.

Underneath layers of sweatshirts and hats was an elderly woman. A deep kindness in her eyes drew me in.

The doctor deftly steered the conversation toward addiction. “Yeah, me and my friends have been partying since New Year’s,” the patient said matter-of-factly. “I like to drink…” The doctor was caring but firm, and pushed a little further, asking the patient about her family and any consequences from her drinking. Tears welled in her big brown eyes. She talked about her son and her husband, how badly they wanted her to stop. For the first time, I could see the person underneath, the person that had been beaten down and locked away by this addiction that overtook the body.

“We can help,” said the doctor. I could sense the woman wanted help. But the force of addiction was pulling her away. Five minutes later, she said, “I need to get out of here.” The doctor tried to convince her to stay, but she put on her coat and walked out.

Soon, a sister called. Even though the patient was gone, the doctor listened to her describe the family’s struggles. I saw how the doctor in her own way felt that same struggle — the anguish of being beaten over and over by a force you cannot even fight.

The doctor hung up, turned her attention to the next patient, and another chance just maybe to reach a patient suffering from addiction.

12:00 P.M.

The third patient I saw was young, homeless, and in crisis. He clutched a bag. “What’s in the bag?” asked the resident. “It’s just my lunch,” the patient replied. As I learned more about this patient, I soon suspected it was not just his lunch.

“How long have you been using?” the resident asked.

“More than 10 years,” he replied.

“How long have you been homeless?”

“My whole life,” he responded.

He pleaded that he wanted to “get better.”

I was confident we could get him treatment. I was wrong.

The patient had come in a week earlier with the same story and one additional detail — he was not taking anti-retroviral drugs that he was prescribed for HIV. These medications are required for him to be admitted to inpatient addiction therapy. The patient this time tried to hide his HIV diagnosis, to no avail.

We made an appointment for him to get his HIV drugs, but I worried he wouldn’t go in his current state; it seemed too overwhelming to him. “Will I have to go there alone?” he asked. The answer was yes.

“Less than a 50 percent chance that he makes that appointment,” the resident predicted.

The opioids that he wanted to stop were preventing him from accessing the HIV drugs that would keep him alive. This was addiction.

I saw several patients that afternoon. The CRC helped me understand how someone’s emotional trauma can lead to the desire to escape life by using drugs.

I no longer wonder what leads individuals down the path to crisis. I now wonder why paths haven’t been built to pull these individuals from crisis. Healthcare systems try, but in my opinion seem ill-equipped. Our system leaves patients who have such needs and challenges to navigate services on their own.

Too often patients find themselves alone.

1:14 P.M.

Al was eating his hospital lunch, a chili burger with slaw on the side, about to be discharged. He was an older man, gray hair. He’d been on the sixth floor for two days. One minute, he said, he had been at the barber shop, and the next he was waking up at Episcopal. He blamed his diabetes.

Al said he moved to the area six months ago, and was living in his own apartment. He told me he had been learning to cook, especially the traditional Puerto Rican recipes of his mother’s. He said his family was located elsewhere, but he preferred to move around, live alone.

When I asked about opioids, he let silence fill the room. Finally, he said that in all his years taking drugs he never injected anything. He only smoked or snorted them. Drugs, he said, just let him ‘feel like a kid again.’

Al finished his apple juice, put on a gray crew neck sweater. I thanked him for his time. A nurse wheeled him out the door.

After he’d gone, I asked the doctors and nurses about him.

Turns out, Al is well known at Episcopal, brought in once a week, typically overdosed on heroin. This last time, paramedics found him on the street, without any clothes. The hospital gave him the sweater he left in along with his other clothes. Al was taken to a shelter, as usual.

Al taught me that there is no single story of what a person with substance abuse disorder looks like. They come from all backgrounds, races, ages and genders. Most importantly, they all have different lived experiences and just want their stories to be heard.

I was honored to have listened to his.

2:08 P.M.

The patient had an overgrown white beard and tea bags under his eyes.

“Well I hope you’re still staying with us,” the recovery specialist said, walking into the room.

“I am, I am,” the patient said.

The recovery specialist gave the man a fist bump and said, “I have goosebumps all over.”

The patient had overdosed that morning. The specialist met him in the ED, and persuaded him to stay, to get treatment.

Two and half years ago, the recovery specialist could easily have been in this man’s place.

He came through a detox and recovery program in 2016, and started volunteering. Helping others helped him stay focused. He shared his story to give others hope.

He soon got his certification to be a recovery specialist. A year ago, he started at Episcopal, part of a new program in which recovery specialists help patients get into treatment, find housing or even just provide support and living proof that it’s possible to break the cycle of addiction.

“I believe my journey and past experiences have led me right here,” the recovery specialist said. “I have been where they are and they open up to me.”

3:15 P.M.

I went through a metal detector to a locked door to a locked elevator to a locked floor. I thought about people working here in the CRC, having to deal with this every day. I thought about the people under their care — under lock and key. As the elevator doors opened, the smell of unwashed bodies hit me with a force I hoped no one could read on my face.

After talking with doctors there, I moved on to the main psychiatric floor. I met a cheerful resident who brought me around to see her patients. One was a cook who didn’t want to stop getting high but knew that drugs would kill him. He mainly smoked K2 and lived with his grandmother, but he couldn’t live with her and use drugs, so he was being discharged in an hour to the streets. I asked him if the guys on his restaurant line did as many drugs as the line cooks I’d worked with. He said they did.

After a few hours at the hospital, I made my way back to my car. I turned right out of the hospital and, by chance, drove past “Emerald City,” the encampment where many people struggling with substance use disorder in Kensington lived until recently, when police cleared the area. Snow was in the immediate forecast. I thought about the cycle of poverty inextricably laced through the cycle of substance abuse.

I felt that swell in my chest that I get sometimes when I think about all the people who have pushed me up to where I am today. All the clawing I did to get here, all the hands outstretched when I was too tired to claw any more. It’s a swell without guilt, without exhaustion, without judgment, without imposter syndrome. It almost always comes with tears.

4:04 P.M.

As a doctor working in a busy Emergency Department in a busy part of the city on a busy morning, having a student with me was both motivation and looking glass. Knowing someone was watching me I wanted to set a good example. I cut no corners and tried to make sure they saw a doctor treating every patient with efficiency, competence, dignity and respect. I hoped this was not today only; I am careful to bring this daily sometimes falling short of the doctor I dreamed of becoming.

In the presence of a first-year student I immediately remembered my early days in the hospital where so little was as I expected it to be. I tried to ask students what they understand. I often forget how much I know now — though I still feel young and new to my job, every shift, every month, every year in the last six since medical school have built experience that make me unrecognizable to my younger self. The students’ interpretations and questions were humbling and reminded me how important it is to teach at the bedside. Having them with me reminded me of the importance of accompaniment. Just like patients need family and loved ones at the bedside to let them know they are not alone I have felt a similar comfort having a student or resident nearby when facing difficult medical problems or the intensity of emotion that comes with Emergency Medicine and Critical Care. Something about sharing the experience in time, whether discussed or moved quietly past, imparts strength.

I worry about the limitations of this project. I often wish in addition to Medicine I had time, the training and expertise of an anthropologist, sociologist, psychologist, and poet. An hour is woefully insufficient to understand the complexity of addiction and its intersection with hospital medicine. And yet, an hour is what we had today. And it took the first student far less than that to understand something of the loneliness, desperation, and despair that drives two Americans in their thirties to bed eight — one in the bed and one crouching beside it.

4:35 P.M.

The drug counselor sat down to a tilapia dinner in the hospital coffee shop. It was the first thing he’d eaten all day.

The night before, a veteran of Iraq had come into the emergency room. Her boyfriend had stabbed her. He regularly beat her, and she started using heroin a year ago.

That morning, the drug counselor found the veteran a new apartment, and then drove her to temporary, transitional housing an hour away. He’d just returned.

“If you really want to help people in the center of the storm,” he said, “this is the place.”

5:20 P.M.

My first impression of Episcopal was that its tower could have been the home of Batman of the 1930s.

Making my way to the sixth floor, I met with a hospitalist. She started working here only months ago. She was unprepared for the inhumanity and despair caused by heroin that she encountered in Kensington. On her first morning at Episcopal, she wept.

One patient we visited was from the suburbs. Kensington was her “get high place.” She claimed she was in Kensington now to try to gain strength by saying no to heroin so that she could finally beat it. She had come in with an overdose.

The doctor listened and didn’t judge. When patients know they are being heard, she said, the chances are greater they will seek help.

6:45 P.M.

Melanie had injected heroin a few days earlier, and the needle broke. It was still in her neck, and now she now had an abscess growing around the needle fragment. For the past 2 years, Melanie said she’d been trying to get into rehab. “It isn’t like it used to be,” she explained. “Now the first thing they ask you is if you have insurance, and if you don’t, they ask you for $20,000.”

With the help of her longtime partner, she’d finally been accepted into a program and hoped to enter any day.

A boyfriend in college introduced her to heroin. She’d been in recovery for nine years, but pain killers prescribed after a car accident plunged her back into addiction. She made a point to tell me the doctor knew of her history with substances.

Melanie emphasized that so many of the people she’s met in Kensington had good lives and are brilliant and that addiction is a demon.

7:26 P.M.

Mr. W. sat in the corner of the waiting area in the CRC, a hospital blanket pulled over his head.

A few minutes later, he was called into a small examination room. He clutched the blanket, pulled up to his neck.

Mr. W., can you tell me why you’re here?” the resident asked.

He didn’t answer. He was fighting to keep his eyes open.

The Emergency Department had given Mr. W. Narcan, then sent him up to the CRC. He had never been to Episcopal before.

“Mr. W, can you tell me why you are here?” the resident repeated, raising his voice just enough to get Mr. W to open his eyes.

“I have an addiction,” he said.

Mr. W. had closed his eyes again before he finished uttering the final syllable. I was struck by his honesty. That was the only history we could get.

On my way out of the hospital, I stopped to ask the security guard about his perspective. He began making a circular motion in the air with his hands. “We see the same faces all the time.”

People, he said, step through the doors of Episcopal with drugs, because of drugs, because of loved ones with drugs, or because drugs gave them nowhere else to go.

A second security guard joined the discussion. Sometimes patients get so used to coming here, he said, that “the line blurs between what the building is supposed to be and what they come to seek from it — warmth and a place to stay.”

8:10 P.M.

The attending, his resident, and a nurse were standing around a stretcher in the hallway. On it lay a young woman, barely conscious.

“We don’t have time for that, she’s dying,” the doctor said. “You guys have to learn to not depend on the ultrasound.”

He slipped on a pair of green, sterile gloves and deftly inserted an IV into the right external jugular vein of her neck.

In another hallway bed was a man found by an ambulance crew just a few blocks from the hospital. His heroin overdose was not yet fatal and allowed a more gentle approach to treat it — a warm place to wake up, a nasal cannula to support his oxygenation.

His oxygen saturation improved to 95%, and a doctor asked if the patient would talk with me. He agreed.

“Can I get some water?” he asked. After his third cup, he started to tell me about himself. He moved from Puerto Rico when he was 19, and started using. He didn’t say for how long or how often, just that his days were hard.

His body started to shake and he asked me for a blanket. I wrapped one around his shoulders, placed another over his body. His eyes fell shut, signaling the end of our conversation.

One doctor told me he’d been at Episcopal five years, and was moving on this summer.

“We see things every day that most physicians may see once in their career,” he said. That sense of futility doctors here feel was overshadowed, in my eyes, by the love and care they showed not only to each other, but to the patients and families.

Regardless of what they said, often voicing a frustration or dark humor outsiders might not understand, they showed me that at least some part of them thinks it may not be impossible to beat this.

9:12 P.M.

After a year and a half of medical school, I barely had a handle on the metric system of dosages, but I was at least familiar with the sound of milligrams and deciliters. I lost my bearings entirely when the resident started to ask how much of each drug a patient was using and he responded in terms of bags, joints and, regarding his Xanax use, bars.

“Six bars, not pills,” he emphasized. “Bars.”

The resident nodded in understanding, but I found myself envisioning hefty bars of Xanax like bars of gold in an old-timey heist movie. A bar is in fact the size of a tic-tac and means a two-milligram dose.

This patient had brought himself to the CRC after going on a “major binge,” one week after he had returned from a drug detox program. He started using heroin, he said, to cope with the death of a loved one. He had entered detox to take back control of his life, and when he left the program, he said that he felt “like he could take on the world.”

He couldn’t remember what prompted him to start using again. He started to cry as he answered the resident’s questions, berating himself for not following through with therapy or with a longer rehabilitation program.

The resident’s voice was calm and quiet, and she pushed a box of tissues towards him.

10:01 P.M.

An older man, still wearing his jacket, hat, and boots, snores under a sheet in a hallway bed. “Over 50,000 patients come through this hospital a year,” an emergency department doctor tells me, “and it feels like 90,000 of them are involved with the opioid crisis.”

Last year, the doctor said the Emergency Department saw over 100 patients and 24 overdoses in one 8-hour shift. The reason was a bad batch of heroin mixed with sympathomimetic drugs called “Santa Muerte” — The Holy Death.

“There were people screaming for 9 hours straight no matter how we tried to calm them down,” the doctor said, and suffering from respiratory depression, psychosis, hallucinations, confusion, and anxiety. “The ‘heroin’ on the streets barely has any heroin in it anymore,” he added.

I wondered: How do doctors handle the drug crisis when the drugs are constantly evolving?

11:11 P.M.

Mr. S. has just been admitted to the psychiatric floor. There’s nothing in his room to suggest we are in a hospital. No EKG monitors, no plastic railings on the bed frames, no sharps boxes or informative posters on the walls. I’m reminded of some older age of medicine, of almshouses and religion.

Though some also struggle with opioids, patients on this floor have chronic and severe mental illness and are awaiting long term placements.

Someone down the hall sings light of my life just put your trust in my heart and another person asks if she can have a cracker and is denied. I look out the window at the new, lazy snow falling brightly backlit in the yellow floodlights of the parking lot. It is nearly 1 a.m. now. The whole city feels slow in this moment.

Maybe I’ll get a nap in tonight, the resident tells me, with a knowing, fatalistic shrug.

12:05 A.M.

A paramedic walks in, pushing a wheelchair with a man slumped forward in a dark hoodie.

I slip in behind the attending, and stand next to the bed. The patient’s had pain in his chest for a week. He used PCP, or angel dust, earlier in the night.

I’m alone with the patient quicker than I had anticipated.

He’s a broad, muscular man.

He agrees to talk to me. The conversation is slow. With each question, I see my words travel in slow mental rollercoaster loops before coming back out as responses. He starts each of his sentences with his eyes closed, opening them as his thought progresses.

I ask him why he uses PCP. He tells me that nowadays it gives him peace of mind, keeps him calm, awake. He started in his teens. He made PCP with his friends, and learned how to manufacture the drug from a family member.

I retrieve a chair and sit by his side. My eyes are level with his now.

His first experience with PCP was bad. He took off his clothes, screamed wildly, hallucinated, lost his wallet, and woke up hours later in the same exact location, but at nighttime.

I ask him why he continued. He struggles to find an answer. Of course, it wouldn’t be that easy.

Other details come tumbling out. I learn how to smoke PCP and how much it costs each day. He’s put himself through inpatient rehab but keeps relapsing. He’s lost multiple jobs trying to stop using PCP; I learn about each one.

He speaks softly, like he’s speaking from a dream, except he’s recounting reality.

He lives on the street. He sees his children around the holidays. “I’m trying my best to stay clean, but they keep pushing me away. They don’t believe me, so I relapse,” he says sadly.

I think about how two decades is a long time. I’m sad that his family doesn’t trust he can turn it around. I can hear the remorse in his voice. I also think about how frustrating it might be to grow up with a parent you felt wouldn’t come back from his addiction.

I ask him if he has any advice for me as a future physician. He laughs for the first time, deep lines creasing his forehead. A corner grin materializes.

“I’m tired,” he whispers.

1:13 A.M.

At this hour, the fluorescent “EMERGENCY” sign pulsates slowly and casts an alien glow on the snow-covered cars.

Inside the doors, the security guards greet incoming patients with rigid politeness. “Can I have your ID sir? Thank you, sir. Turn around please, sir. Lift your hands up please. Take your hat off please.”

A guard explains to me that he found a razor blade in a hat once, so now he asks everyone to remove his or her hat. He wands the patients down with a handheld metal detector, pats down anything suspicious, and then sends them through a full-body scan and their belongings through an x-ray machine.

“We see a lot of crazy things,” he tells me, and behind his desk, he has the proof — a trashcan filled with confiscated items. I peer over the top and sure enough — bottles of gin, hipflasks, numerous knives, and a rusty can-opener lying atop a bottle of lighter fluid.

In the waiting area, patients sit on heavy metal benches. I see men and women of all ages, many skin colors and all manner of clothing, loafers and slippers, designer jeans and sweatpants. White or black, young or old, they are all very much alone.

2:07 A.M.

The patient was only a bit older than me with tattoos and scabs on his arms and hands. The scabs were also on his neck where he admitted to regretfully injecting once or twice.

He’d come to have a physician take care of what appeared to be an abscess on his right forearm and he wanted to be sent to a top Philadelphia treatment center for drug rehab.

He told me his life story. His parents struggled with addiction and divorced. A neighbor molested him as a boy. He was in high school when a classmate offered him a Xanax, and immediately felt “all was right.” And wanted more. An injury led to a surgery and with that came his first Percocet. He told me he convinced his physicians to give him more Percocet than he needed, and places no blame on them for giving him what he wanted.

Eventually the Percocet turned to heroin and fentanyl. Along the way he burned the bridges with his parents, who had turned their lives around.

He does not blame his parents for his troubles. “I played the game of ‘the world isn’t fair’ and it got me nowhere.”

He attended different rehabs over the years, and met his girlfriend in one program. For six months, he didn’t use, but after an argument, he used heroin, and began a downward spiral.

He wanted to get back into treatment. He wanted to get well and return to his girlfriend and her child. And if that meant sitting in the CRC waiting room going through withdrawal, so be it.

After we talked for a good half hour, maybe more, he said he was hoping the physician would return to inspect his wound. I took that as my cue to notify the physician, so I thanked him for sharing his moving story with me and wished him the best. We shook hands, and I closed the door on my way out.

I let the doctor know that “the patient was hoping you would take a look at his abscess,” sad that I hadn’t used his name.

3:00 A.M.

He was a behemoth of a man. He had come on his own in the middle of the night because he could not sleep. He had been having hallucinations. He had been unable to go to classes, forcing him to drop some courses. He had prescriptions for a very high amount of Adderall and for Xanax.

These two drugs as explained to me do not seem to work together. Adderall is an upper, while Xanax is a downer. Although, by his account, they seemed to be working for him. He’d been taking them for two years, become dependent, but he was now between doctors and could not get an appointment — or his prescriptions refilled — for another five days.

Out of pills, desperate, he’d come to the CRC.

Earlier, I’d asked the doctor what the public should know about addiction. She replied: medicine often precipitates people’s addictions, and the medical system can make it difficult for people to get the care they need.

I was thinking this must be an example of exactly what she meant.

4:15 A.M.

“I ain’t no fool,” says B Money. “I’m just in bondage with the devil.”

B is on his 17th hour at Episcopal. He sits perched in a wheelchair in the Crisis Response Center. The dozen or so other patients are mostly asleep or sobbing. B, however, was alert, talkative and gave the impression there was no crisis at all.

His family brought him to the CRC after he was talking about killing someone.

B considers himself a protector of his neighborhood. He shows newcomers how to navigate the “trap houses.” If they have a bike or $10 in their pocket, he says, he makes sure they aren’t robbed.

B insists he is not “a crackhead,” simply a smoker. He says he stays away from heroin. “We don’t play with that dope, because you die quick. We don’t allow that heroin in our neighborhood.”

B has been using crack for many years, interrupted by a few stints in rehab. “I went to church and got 1 year… The temptation brought me back.” He’s a spiritual person, he says, but not partial to any one faith. “I just know God … has a plan for me.”

He wants to go back to a rehab facility outside of the city, one with a lush campus and group therapy. “For me to really make it I have to change my environment,” he says.

B’s desire for change conflicts with his sense of duty. “I guard my neighborhood,” he says. “There’s no one else gonna do the job.”

Despite his commitment to recovery, doctors feel he lacks insight into why his family brought him in. He still poses a threat to himself and others. He will spend a few days on the inpatient floor. A social worker will search for a rehab with an open bed, while he recovers his awareness of reality.

B fully believes in his capacity for change. “I bet on myself,” he says. “Always bet on black.”

5:12 A.M.

I was leaning against one of the ER counters, taking in the calm that had settled over the area when a patient who had come in with shoulder pain burst out of his room. He came bustling past the desk, winter jacket open, a bag of life’s possessions slung over his shoulder. On his way past he grumbled loudly enough for everyone to hear, “They just kick out junkies here!”

The doctor that had been in to see him looked at me. He said they hadn’t even talked about pain management yet, just that the patient would need another appointment to get an MRI.

The ripples of the outburst quickly faded, the patient gone into the night, and that same calm re-emerged.

The doctor and I had a long discussion, in part because the night was slow. He talked about the challenges of addressing chronic pain in patients without contributing to addiction. I pondered that patient’s situation. Maybe he’d come in seeking opioids and when he realized he wouldn’t be getting them, that he’d first need an MRI, he stormed out in anger. Or perhaps the patient had had adverse healthcare experiences in the past that primed the intensity of his emotion. I guess I would never know.

Soon enough the next shift of nurses and doctors began arriving. Night was turning into day, and I sensed that the hospital would soon be springing to life again. I put on my own coat and headed into the cold.

The End