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The education of a doctor and the heroin addict she tried to help

March 27, 2017

Drawing by Mai Stewart, a second-year LKSOM medical student.

He was living in his wheelchair, open wounds, drawing flies and maggots.

He’d shoot heroin every day. He used the same needles. He wasn’t going to give himself HIV, and he already had Hepatitis. He’d sell the clean needles he’d get from the needle exchange.

He was smart. His social security disability check, he said, went right to the check-cashing store. He could even get a loan against next month’s check — buying heroin with borrowed money.

He was 40. He’d been living this way, on and off, since 18, when he became a paraplegic after a foolish, tragic joy ride in a stolen car. He was in the backseat. Chased by police, the stolen car ran a red light at 3 a.m. and was broadsided by a delivery truck. The girl next to him died.

For the last year, he’d been living on the corner of Kensington and Somerset, in his wheelchair, the seat cushion lost, pressure sores on his rear end growing worse. By the end of summer they were exposed to the bone. He faced a choice.

Get high, and continue to let the maggots crawl into his open sores and other orifices. Or go to the hospital, and endure the misery of detox and face his life for what it was.

He wheeled himself into the ER at Episcopal Hospital, and after a rapid, three-day detox, he was transferred to Temple University Hospital.

He was assigned to a physician who was new to Temple, in a temporary position, working for three months as a hospitalist, someone who cares for patients admitted to the hospital.

“The maggots were cleaned off by the time I met him,” the new hospitalist recalled, “but he was given a private room, just in case.”

•   •   •

The hospitalist had worked in a private practice in suburban New Jersey for 20 years. “I didn’t feel that I was really changing anyone, changing the world in some significant way,” she said. “If I stopped practicing, they would just go down the street to someone else.”

She had studied integrative medicine for two years with Andrew Weil — the famous mind, body, spirit guru — and authored a grant proposal at the VA for an integrative medicine approach to PTSD. She spent three years at the VA Medical Center in West Philadelphia, and the homeless veterans moved her most profoundly, many of them addicts.

After leaving the VA, she came to Temple. She asked that her name not be used in this story because she felt it was more about her patient. The patient also consented to this story, but requested anonymity.

The new hospitalist rounded on her other patients, and walked into this patient’s room last. It was around Labor Day.

“What happened to you?” she asked.

“What do you mean?”

“How did you get to this point where you’re covered in maggots, living on the street?”

He told her his story.

His father left when he was a little boy. He fought with his stepfather. He left home at 16, lived on couches. He was smart, but failed in school.

“After the third month of my second year of 11th grade, I was totally disinterested,” he said. “One day I just walked out.”

Then the fatal car accident. “She died over a stupid joy ride,” he said. “Stupid. Senseless.”

A friend introduced him to heroin.

“I felt like I did before the accident,” he says, “but just too lazy to stand up.”

Twenty years rolled by: Living with girlfriends, living in cars, living in his chair. Getting high. Going nowhere but down.

•   •   •

“Well, have you had enough?” the doctor asked him. “Are you done?”

“I see you as a person who has something to offer,” she continued. “I think I can help you. I think we can find your gift.”

He was a homeless heroin addict who had long past given up hope in a future for himself.

But he was surprised by her candor, her concern. Nobody had ever taken such an interest in him. On the streets, everyone always had an angle. He surprised himself. He let her in.

“Lots of people tell me I have some purpose,” he said, “but what purpose is it?”

“Let’s find out together,” she told him.

She walked into his room one day carrying a large bag.

“What’s this?” he asked.

“It’s your new wardrobe. You new life.”

He had nothing. At Costco she bought him underwear, pants, socks, shirts, a sweater and even new winter boots.

She also bought him books. He read The Five People You Meet in Heaven by Mitch Album, a book about the meaning and value of every life, which spent 95 weeks on the bestseller list. He read it in one day and had tears rolling down his cheek when she walked in. She bought him The Catcher in the Rye as well as This Boy’s Life. “I wanted him to see that many people feel alienated and abandoned…”


His private room with the books the hospitalist gave to him.

She brought him GED study guides.

She would talk to him about getting dentures, an ID, finding a place to live. She had visions of him working, maybe at a hotel reception desk.

“She’s a saint,” he said of her one night. “I actually have trust in this woman. And that’s hard to say.”

“I know she’s getting the stink eye from other doctors,” he added. “`Why are you helping him? He’s just going to go back and do heroin again?’ I hear it. I see it.”

Other doctors had no problem with her helping him. They all cared just as deeply. But they had been in the trenches a lot longer.

He also knew the enormity of what she was asking. “Do you know how hard it’s going to be, taking the steps, doing the things I need to do?” he said one evening. “That’s so crazy. It’s so much easier to say the hell with it.”

As she helped him, he also helped her. He taught her about the culture of heroin, how it cost a fraction of a pack of cigarettes, and how he survived on the street.

“I guess you could say we educated each other,” she said.

•   •   •

He was on a unit with great nurses. When they ordered out, they included him, getting his favorite, a pizza steak. They brought him coffee from Starbucks, watched the presidential debate in his room with him. They liked that he was honest about his addiction, made no excuses.

“It was as if he was so isolated from society that he was shocked that we actually sat down to converse with him,” said Nurse Indira Kupa.

He “eventually became the Mayor of 4 East,” the hospitalist said. He was often out on the unit, in his wheelchair, hanging out. One day, a nurse put supplies in his lap, and asked him to carry them down the hall, from the storage room to the nurse’s station.

“Happily, my dear,” he said.

He was sleeping in a bed with clean sheets. He had a recreation therapist take him outside daily. He placed his breakfast order with the attendant as if he were at the Four Seasons: “I’d like extra hash browns, and extra bacon, please.” Kupa would joke with him, “You have your own studio apartment! Your own bathroom.”

As the weeks went by, his wounds were healing and he was gaining weight, nearly 30 pounds, getting soft in the belly. Other medical issues were being addressed.

But the reality also started to sink in. His days at Temple were numbered. This doctor would be gone. He would be gone.

These nurses who had treated him so well would be treating someone else.

One night, the hospitalist stopped into his room and said, “Do me a favor. Think about what you want to do with your life and how you see your future.”

“What future?” he replied. “When I’m done here I’ll be back on the street. That’s just the way it is.”

“You’re right,” she said. “If that’s what you choose. But you have to create other choices.”

By mid-October, he stopped reading her books, or opening the study guides. He started to get despondent.

What had he done to himself? Would he be lean and mean enough to survive if he returned to the street, especially as fall turned to winter?

Had hope and comfort been the worst possible thing?

•   •   •

One day a young woman came into his hospital room. She worked for an outside agency and was there to verify his Medicaid eligibility.

She shuffled through many forms, and apologized if she seemed disorganized, which she did not.

“I just came back to work,” she said. “I was in detox. Got to be honest.”

His eyes widened.

She asked him questions.

“What brought you here now?”

“Decubiti,” he said. He sounded like a doctor.

“Can you take any steps?” she asked.

“I can’t even stand.”

More questions. He finally interrupted.

“I’m sorry, but can I ask you what you were addicted to?”

“Heroin,” she said.

“Hey, I’m a heroin addict myself,” he said.

She had been working, but stealing from her parents to support her addiction, and fearful she’d lose her child. Her life was unraveling and she couldn’t live like that anymore. She went to rehab, got clean.

He looked at her with admiration, even pride.

“You just made my day,” he told her.

•   •   •

The day had come. He no longer needed to be in a hospital.

He needed wound care, so the bedsores on his rear, the decubitus ulcers, could finish healing. He needed a nursing home.

But no nursing home wanted him.

Temple discharges 2,500 patients a month, 200 to nursing homes. Nursing homes want patients with private insurance, who have homes to go to when they no longer need skilled nursing care, and who are not drug addicts.

He fit none of those criteria.

“We had two or three nursing homes that would take our drug addicts,” said Maryteresa Mintz, the director of clinical resource management, who oversees discharge planning at Temple. “But they’ve been burned too many times by bad behavior, friends smuggling in drugs, patients with no place to go.”

“If you’re using when you come into Temple,” she said, “nobody wants you when you leave.”

This difficulty finding a good placement for her patient deeply upset the doctor. She would be on the phone, daily, calling facilities herself, vouching for him. No luck.

By the end of October, they found him a nursing home in Norristown.

“Is it the best? It’s the best available,” said Mintz. “It’s the best we can do given the situation.”

A transport team came to get the patient one evening. They took his books, his new boots, his clothes, all his worldly possessions. He left in his own wheelchair.

The hospitalist was gone too. Her temporary stint at Temple was over.

She would work on projects to eliminate veteran homelessness and drug addiction through Integrative Medicine.

•   •   •


Illustration by artist Jonathan Thomas.

Like this doctor, the country has woken up to the opioid epidemic.

More than 33,000 people in America last year died from an overdose of heroin or some opioid.

Nine hundred in Philadelphia died of a drug overdose in 2016 — double the number in 2013.

“Every day, we lose ten Pennsylvanians to the disease of opioid addiction and 3,500 Pennsylvanians lost their lives in 2015 alone,” Governor Wolf said on Jan 30 during a visit to the Lewis Katz School of Medicine’s Center for Substance Abuse Research.

It was no surprise this patient went to Episcopal’s emergency room. The DEA considers where he was living, just blocks from the hospital, the largest heroin market on the East Coast. The Philadelphia Inquirer just reported that tens of thousands of used syringes line the embankment of Conrail tracks cutting through the neighborhood.

In one week recently, Temple and Episcopal — both part of Temple Health — treated more than 70 patients for overdose, withdrawal or addiction as a primary diagnosis.

That number is deceptively low, says Temple ER doctor Joseph D’Orazio, because many addicts also came in for injuries or infections related to drug abuse — such as an open wound filled with maggots.

Temple also is making plans to expand its care for addicts inside the hospitals and out, before they arrive and after discharge. “If this place can’t be a leader in addiction treatment and research, who can?” said Larry Kaiser, president and CEO of Temple University Health System.

Temple doctors know the enormity of the challenge.

Said one clinician: “A lot of these addicted patients have burned every bridge behind them.”

•   •   •

The doctor kept in touch with her patient in Norristown, and when he got out around Christmas, she put him up in a modest hotel for a week.

“It was freezing outside, literally,” she said. “Anyone would have done it.”

She gave him a computer to use. Told him to look for handicapped accessible apartments to rent. She was even willing to help with rent money at first.

But he had to meet her half way. She wanted him to get a state ID, a first step in turning his life around. She had worked hard to get Medicare to provide him a new wheelchair, but he needed a permanent address in order to receive it.

In her opinion, he wasted the week. He watched TV. She didn’t know what he did.

But in her mind he made no effort to establish himself.

So he was on his own.

He had a cell phone, but they lost touch. Last the doctor heard, he was living in the backseat of a car. According to his brother, he was back on the streets of the East Coast’s largest heroin market. He was using.

“I’m saddened that he has not reached out,” she said. “I was expecting more from him. He was shown another way, so it’s not like he doesn’t know it exists.

“He called his life `Bohemian,’ ” she added. “I told him `Bohemian’ is for trust funds. Homeless is for everyone else. He’s made his choices.”

There must be a way to reach people like her patient, she said, and help them find their way.

Kupa, the nurse still on 4 East, said she thinks about the doctor and patient often, because the former tried so hard and the latter had so much potential. When told the patient was back on the streets, she said, “I just wish he could have seen in himself what the doctor, myself and many others saw and hoped for him to be.”

•   •   •

Michael Vitez, winner of the 1997 Pulitzer Prize for Explanatory Journalism at The Philadelphia Inquirer, is the director of narrative medicine at the Lewis Katz School of Medicine at Temple University.