Death Diminishes
by Tom Crowley
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Table of Contents parts: 1, 2, 3 |
part 1
A few years ago in June, the foothills’ exploding patches of blooming golden banner brightened Everston’s drive to work. But when he arrived, his mood darkened. As he did before meeting any new patient, he thought of his businessman father, drunk, fighting a cop, and billy-clubbed to the sidewalk; and his mother, who couldn't recognize him through the dense fog of her alcoholic dementia. These memories and years of experience as a therapist had led him to surprise his colleagues at a conference with the question, “Why do we continue?”
“The answer,” he had said, “is in lines four hundred years old that we learned in eighth grade. As Dean of St. Paul’s cathedral, John Donne had conducted many funerals. Later, seriously ill himself and writing from his rectory sickbed, Donne still heard each day the cathedral’s funeral bells.”
Everston, wearing his version of the local psychiatric uniform — blue dress shirt, a bit of art on a silk tie, khaki chinos, comfortable shoes — reread Donne’s lines from a card, then put it away before he opened the office door. He walked a few steps to the man sitting in the hall and said, “Good morning. I’m Doctor Everston. Please come in.”
Everston closed the door and shook the hand of the man, who said, “I’m Doctor Andy Karnik.” More than his title, Karnik’s firm handshake, resonant voice, his flawless dark suit and senatorial tie proclaimed a distinction — one unsupported in the referral documents Everston had seen.
Before sitting Karnik enthused, “I love your office: huge old window; big work surface in warm, deep red; even dramatic stage lighting on the desk top.” Approaching the dark wooden shelves, he said, “And wow, look at the historic books: The Origin of Species, Gray’s Anatomy, even Beyond Freedom and Dignity. You know, my Harvard Master’s was in experimental psych. Skinner was old then, but he still came around.”
Motioning Karnik to a seat on the sofa, Everston thought, Sophisticated snowjob, although Everston also liked his office in the university’s old psychiatry building. Indeed, when the department balked at its cost, he, himself, had made that deep red laminated desk and work surface that ran the length of one wall.
Behind Everston, who was facing Karnik from his desk chair, hung a framed poster: a lone runner starting down a road that wound far across a verdant treeless prairie. The caption, “No finish line,” warned patients that substance-use disorders are never “cured.”
When little, Everston’s kids loved jumping from the small sofa onto the work surface, out the open window, and down three feet to park-like grass, climbing back in to do it again and again. When departmental politics turned awful, as they often did, Everston joked that he might some day end it all with a three-foot leap from that same window.
He was aware, of course, that while housing seventy years of pain, sorrow, and suffering, this building had known unfunny leaps.
“Let’s start with confidentiality,” said Everston. “I’m obsessive about it, because breaching it could end your career. We both know that the Board of Medical Examiners, BOME” — which he pronounced Boh-mee — “referred you here for substance problems after a three-week detox at St. Anne’s Center. BOME will get reports from me, but only: did we decide to work together, what’s the treatment plan, and are we following it — no details of what’s said.”
Shrugging, Karnik said, “Sounds good.”
“OK, here’s that in writing,” said Everston. “Please read it very carefully, and ask about anything that’s unclear. If you don’t like these terms, then we should end this meeting before you say any more, but if they’re OK, sign, and we can talk.”
Without reading, Karnik signed and handed it back. Everston’s eyebrows raised a little as he thought, Risk-taker, but he only said, “You’ll get a copy when you leave.”
“Now, names,” Everston continued. “When two docs collaborate on a patient’s treatment, they usually use first names. But here, I’m a psychiatrist specializing in physician substance abuse, and you’re a physician-patient needing evaluation and treatment. To keep that straight, I’d like you to call me Dr. Everston. What should I call you”?
“‘Andy’ works.”
Everston said, “OK, Andy. You’re fifty-one years old?”
“Right.”
While thinking, Three years older than me, Everston said, “I’ve read BOME’s and St. Anne’s referral documents, but I want to hear it in your own words: what brings you here today?”
“Well, ophthalmologists still use cocaine for local anesthesia and, about two years ago, I started snorting it before dinner, maybe once a week. After a few months it became daily, including some at work, at first from my anesthesia supply. But pretty soon I worried that DEA would see my purchases increasing, so I found a street dealer.
“Within a year I was using maybe six or seven snorts a day, and a couple more after getting home. Eventually, I started watching TV after my wife went to bed, and I’d use more then.”
“Always snorting?”
“I first injected IV last April. It hit fast and hard; unbelievably strong, a whole-body orgasm. I did four more injections that day and evening and never snorted again. At first I used antecubital veins with long sleeves to hide the marks, but I switched to foot veins for better hiding.”
Everston asked, “Did it affect your work?”
“Not my patient care. But I was so damn tired in the morning that I usually got to work late — and I operated two mornings a week. This bitchy nurse who never liked me runs Lutheran’s O.R., and she told everyone that my lateness wrecked their surgery schedules.”
Withholding comment, opting now for neutral acceptance, Everston asked, “What happened next?”
“The Chair of Lutheran’s Credentials Committee called me in. He claimed he could demand stat urines at any time and, if I didn’t give one immediately, he’d suspend my hospital privileges. He’s an ophthalmologist, like me, but not very successful. He wanted to suspend me to get my patients, so I went along.
“Of course, the urine was positive for coke, so he suspended my privileges and contacted BOME. A week later they suspended my license, referred me to St. Anne’s, and then here to see you.” Leaning forward, now emphatic, Andy added, “Naturally, that damned chairman is now stealing my patients.”
“Did you ever try stopping?”
“My practice is big, and patients love me. I couldn’t abandon them for a long rehab. But sometimes at two a.m. I’d write on a yellow sticky, ‘Don’t use today,’ and put it on the mirror where I shave each morning.”
Scrunching his face, looking doubtful, Everston asked, “Did that help?”
Shrugging, Andy looked down. “Oh... sometimes I’d delay starting for a couple hours.”
Everston next asked, “Were you using alcohol or other drugs during this time?”
“Sure, booze cools coke’s high.”
“OK. Now, there’s the same amount of alcohol in a bottle of beer, or a five-ounce glass of wine, or a one-and-a-half-ounce shot glass of liquor, so how many of those ‘standard drinks’ would you take in twenty-four hours?”
“Oh, maybe five.”
Everston pushed. “How many if the high got really strong?”
“Eight was probably tops in twenty-four hours.”
“Any other drugs?”
“Just Vitamin D3, like nearly everyone these days,” answered Andy.
Then Everston said, “Let’s talk about age of first use, and age of at-least weekly use, for various drugs. How old were you when you first smoked tobacco, and how old when you started using it at least weekly?”
“First cigarette, age nine. Weekly use, not sure, maybe... eleven.”
Everston asked, “When did you start smoking daily?”
Appreciating this orderly process, Andy visibly relaxed. “Well, seventh grade, so probably... twelve. Then I smoked every day until Med School, and then just weekends.”
“How about marijuana?”
Andy said, “First use, age eleven. Weekly, about fourteen. I smoked on the way to high school every morning. In college I smoked every night and still do, but just two joints.”
“How about alcohol?”
“First can of beer was sixth grade, so... eleven. Using weekly was probably eighth grade, maybe thirteen. In college, I binged a lot on weekends and had some blackouts — you know, when the next morning you can’t remember the night before.”
Everston asked, “First time drunk?”
“Eighth grade. A girlfriend’s parents had a big liquor cabinet. When they were gone we got smashed, maybe... five times.”
“Opioids?” asked Everston.
“Just briefly after a root canal.”
“Sedative-hypnotic, anti-anxiety, or sleeping meds?”
“For years I’ve taken two fifteen-milligram Ambiens at bedtime every night.”
Everston said, “That’s more than the recommended dose and duration.”
“Yeah, but I’m a doc,” replied Andy. “I know pharmacology and how to be careful with it.”
Storing that contradiction for later, Everston continued. “You said that besides lots of alcohol and coke, you only take Vitamin D, but each night you also take marijuana and excessive doses of Ambien?”
“Well, marijuana and Ambien aren’t addictive. They’re my regular daily meds, like the vitamin.”
Easing off a bit, while still challenging, Everston said, “Yeah, I see that. I’m just trying to picture the various pharmacologic insults your body took while you used coke.” Despite his pushing, he noted Andy’s posture relaxing, suggesting some relief from Everston’s respectful inquiry.
Everston next said, “Let’s go back to coke. Where did you use it?”
“Daytimes, in a private room at my office. At night, just in my home — well, also, sometimes in my car after buying it.”
Everston said, “You’d shoot up and then drive home?”
“Yeah, but I drove very carefully.”
Not responding to that contradiction but storing it away, Everston asked, “Who have you used with?”
“My wife usually snorted with me, but she’s not a physician and injections scared her. I offered to inject her, but instead she quit totally when I went IV. Now, she’s always on me about my use.” Shaking his head, he added, “She’s sure putting some rough spots in our marriage.”
“Well, probably we three should meet together,” Everston said, before moving in his chair to mark a shift. “Now tell me about payoffs and costs — the good and the bad things — about coke. What were the payoffs?”
“Well, that feeling from injecting. I can’t describe it. It sent me over the moon. Unfortunately, it gets weaker and weaker, so you need increasing doses.
“Another good thing: coke made me more alert, so it actually improved my patient care.”
Also filing that away, Everston asked, “How about bad effects?”
Andy looked downward, embarrassed. “Well, I lost fifteen pounds in six months, and I slept so little that I dozed whenever I wasn’t high. Weight loss, sleeping through Med Staff meetings, plus that O.R. bitch... those probably tipped off the Credentials Nazi.
“Also, like I said, the pleasure decreased. Eventually, without coke, I was depressed. Then it wasn’t for pleasure. I needed coke to stop the damn depression, just to feel normal.
“Another bad thing: I think I had two seizures. I injected, and then woke up on the floor. Once, the needle was still in my foot, bent, and a vase was broken beside me. The second time, I awoke with some face pain and got a big shiner.”
“What did you do then?” asked Everston.
“Well, I was amazed that I could do surgery so well in the morning after a seizure, but it scared me, so both times I made myself abstain until one pm. That was hard.”
“So sometimes injections gave you seizures. But you could drive safely after injections?”
“Sure. I only had seizures at home,” replied Andy.
Everston, thinking, Let it go for now, maintained his calm face and voice. “OK... now tell me, were you ever in trouble with the police or courts?”
“Yeah, some high school friends stole cars. I went joy-riding with them in a BMW, and we got busted. They stole it, so they got six months in juvie. Since I just jumped in when they picked me up, I only got a year’s probation. But my damn P.O. had a bug up his ass about marijuana, and I wouldn’t stop using, so I also got six months in juvie. Fortunately, I kept clean for a while after that so, when I turned twenty-one, the record was expunged and didn’t affect med school admission.”
“Also,” said Everston, “the BOME referral says that about half your patients came for Chronic Fatigue Syndrome. It says history-taking was just the patient circling CFS symptoms on a checklist and that your physical exams were just vital signs. Those patients apparently got stimulant prescriptions, Dexedrine or Adderall, and they say you charged three hundred dollars for a fifteen-minute visit. BOME seems to believe you were selling prescriptions to addicts.”
Nodding vigorously, Andy said, “Yup, my lawyer is sure they think that. The whole damn medical establishment thinks CFS patients are all addicts or malingerers. But docs who treat them know how much they suffer and how grateful they are for any help they get.”
Everston said, “I’m no CFS expert, but I think there’s not much scientific support for treating it with stimulants.”
Andy countered, “Science studies are fine, but what’s really informative is the gratitude of patients getting help for a terrible disease.”
Everston, a fisherman gently reeling in, didn’t argue.
Further questioning revealed that Andy’s father, also a physician, had died of alcoholic cirrhosis at forty-nine, that Andy had made the AOA Medical Honor Society at med school graduation, that he and his wife had two kids in college, and that he had no significant medical problems, prior history of psychiatric problems, nor current plans for suicide.
After setting an appointment to see Andy with his wife in two days, Everston ended the session, saying, “Now I’d like to collect a urine sample from you, unless you just want to tell me that it would be positive.”
Andy answered, “Positive for coke, THC, and Ambien.”
Everston said, “St. Anne’s wrote that, when you left there, you were free of all those.”
“That was a week ago,” said Andy.
Driving home that evening, Everston’s mind replayed the session, while foreseeing another sad, silent dinner. His wife, Pat, had been withdrawn since one of her co-workers — maybe a lover — had moved home, and she wouldn’t discuss it.
* * *
Copyright © 2018 by Tom Crowley
