I spent weeks scrolling and re-scrolling through the patient’s medical record before I found it. I read his chart front and back before I started my nursing duties for the day, and well after the hallway lights had been turned off. I noted his labs, radiology reports, operative procedures, medications, history, and physical reports from several different kinds of specialties: primary care, urology, endocrinology, dermatology. I read every single page of his medical record sent from prior facilities, a document of a thousand pages no doctor or nurse had time nor desire to read. Medical documents like these were usually faxed, printed, and re-scanned by a team of technicians who worked behind locked doors next to the IT department on the seventh floor. An employee would queue up the stacks of paper and scan them as fast as the machines could swallow them, not taking the time to ensure the papers were in order or scanned even right side up.
Now that I’d found it, I had to decide what to do next.
John, the patient, was in his late 50s. He was neither fat nor tall. He wore nondescript clothes, wire-rimmed glasses, and the overhead fluorescent lights reflected off his shiny skull. He was quiet and always looked deep in thought. John was also a nurse. He worked across the street at the hospital and was well regarded for having over twenty years of experience working in the intensive care unit. He’d seen deterioration and death, repair and re-rebirth—John had seen it all.
He’d cared for the rich, the famous, the homeless, and just about anyone who could stumble up the city’s congested metro escalator and into the hospital entrance that lay only a few feet away. Intensive care usually meant patients shared a room full of machines that breathed, dripped, beeped, and fed the incapacitated, allowing the patient’s body a chance to (hopefully) repair itself. John had the kind of knowledge and nursing intuition many of us only dreamt about.
Doctors trusted John’s judgement and frequently heeded his advice on critically ill patients. John followed through on his nursing duties, no matter how tired he was. For someone who worked the night shift full-time in a level one trauma hospital, and attended full-time graduate school during the day, I’m not sure when, or if, he ever slept.
I knew John as a patient in my urology clinic. We followed his recovery from prostate cancer. The severity of his case wasn’t bad, but it wasn’t great either. John had his cancer treated by cryotherapy, a middle-of-the-road kind of procedure that is more aggressive than watchful waiting or external beam radiation, and less aggressive than having the prostate surgically removed through the abdomen by way of robot or manual incision.
Regardless of the degree of invasiveness relative to others, cryotherapy is a serious and tenuous procedure. It involves injecting very cold (-40C) argon gas into the prostate, using tiny needles secured by a square, metal grid placed against the perineum. The surgeon uses rectal ultrasound to guide insertion of the needles to the desired spot. Ideally, the cancerous tissue is cooled and ablated, and the healthy tissue remains unaffected. Most patients go home on the same day with a urinary catheter to keep the urethra open, which is removed about two weeks after surgery, allowing the patient to urinate independently.
For this reason, John was prescribed medication to manage post-surgical pain. It wasn’t unusual for patients to request refills for “light doses” of narcotics such as Vicodin. At the time, it was also acceptable to simply call the pharmacy to order refills on behalf of the patient. Other narcotics, such as Percocet or Demerol required watermarked, handwritten scripts. No amount of begging would convince any reasonable pharmacist to accept those prescriptions verbally.
John, on occasion, would call my nursing line to request a refill. I’d pass the request onto the doctor who didn’t think twice about granting me permission to call it in. So I did, charting the refill like I’d been taught.
Then the requests came more often. John started acting cagey, citing emergency circumstances, but not making the time to come in. Irritable and short-tempered on the phone, he snapped at me.
“I have school and work! There’s no time for me to wait in the doctor’s office. Trust me, I know what I need, I know what I’m doing!”
By the fourth or fifth time of him calling me in under a year, I wasn’t so sure he did. I started digging into his medical records, looking into places that bordered on the need-to-know, even for a urology nurse. We took privacy very seriously and had been extensively cautioned against rifling through records that weren’t related to our specialties.
But I couldn’t ignore my gut feeling: John was in trouble.
Not only had John’s primary care doctor and endocrinology doctor been prescribing him Vicodin and sending them to different pharmacies around the city, but three other outside physicians had also been prescribing him pills. I called the pharmacies. They all confirmed John’s prescriptions.
Assuming the charting was correct, and that John collected on all his prescriptions, John could take one pill every eight hours for a full year nonstop.
1,095 pills of Vicodin, which is a combination of hydrocodone and acetaminophen (Tylenol). That means a person is at risk twofold: the average fatal overdose of hydrocodone is 90 mg, and 4,000 mg of acetaminophen per day, the latter having a huge effect on liver function. His prescription was 5 mg hydrocodone to 325 mg of acetaminophen. Either way, eighteen pills could kill him, or he could die sixty times over.
The question I had to ask: did these numbers amount to addiction?
Prior to John, my only other experience with drug “abuse” was in nursing school when two of my classmates were caught stealing flu vaccines—hardly an addiction problem, but it highlighted the fact that nurses have access to a lot of medications that the regular population doesn’t. My classmates claimed they stole the vaccines so they could give it to their friends, and then were promptly kicked out of school.
When I worked in the operating room, we had liquid cocaine meant for post-operative bleeding for nasal surgery. There were gas anaesthetics in every surgical suite and forgetful (or lazy) anaesthesiologists who left their drug drawers unlocked. We had crash carts with lifesaving drugs around in the hallways. When I came to the urology clinic, we had cabinets full of pharmaceutical samples of Viagra and Cialis, drawers full of antibiotics, and we kept a steady supply of sedatives and muscle relaxants meant for in-office procedures. Taking any of them would have been easy. Opportunity and temptation was always around.
I turned to medical journals, Google, and the physicians to solidify my understanding of the signs and symptoms of addiction: irritability, agitation, mood changes, social withdrawn behaviour. John seemed to have them all.
I begged him to come in to see the doctor, even on his preferred date and time. He refused and later stopped returning my calls, opting to leave me angry messages about how I was ruining his life if I didn’t just call in his medication. My job after all, was to help patients, not to harm them. He and I had gotten along well throughout his treatment, and I admired his strength and fortitude in balancing his life despite living with a cancer that could come back at any time. But our relationship turned sour when I asked him, “John, how’re you managing your pain in between Vicodin doses? Have you considered lower level analgesics?”
“Damnit! None of that stuff works. Doesn’t even put a dent in the pain. I need Vicodin, so please do your job and follow up with the doctor. This isn’t your call,” he retorted.
I was terrified at the thought of being responsible for disrupting John’s personal and professional life, mostly because I wasn’t all-the-way certain. My spirit was crushed with this suspicion, knowing that an addiction put not just him, but others at risk. Plus as a nurse myself, I was expected to report things like this. It was my ethical and legal obligation. Impaired nurses are astronomically at higher risk for making mistakes at work, mistakes which can be a matter of life and death. My distress increased even more when I sought out doctors for support.
“Does John’s medication history seem excessive to you?” I asked them. I inquired further. “How can this situation best be rectified? Can you please give him a call to check in on him?”
“Yes, I agree someone should look into this,” one of them said evasively, before slipping past the door, hurrying to be anywhere else.
Another suggested that I “should just leave it to the pharmacy.”
None of the outside doctors even returned my phone calls.
Amid these one-sided conversations, I grew increasingly frustrated that no one felt compelled to help him or me. It was clear that no one wanted to take the blame, no one wanted the scrutiny. I understood that feeling, I didn’t want any part of this either.
I hated myself for wanting to hide my head in the sand, and spent many sleepless nights worried more about what John thought of me, rather than about his safety and mental health—though that worried me too.
I second guessed myself.
Was I just being paranoid? Was he really sick? What would happen if I called the nursing board?
Even though the city had programs designed to assist drug addicted nurses and get them into rehab with an ideal, eventual return to work, I wondered if I would be ruining his life.
Or would I be saving John?
Maybe I would be doing both.
Would he forgive me for being a rat?
Probably not.
I picked up the phone and made the call.
Emily Schlink is an American writer and nurse. She lived in Namibia where she was a founding contributing editor of Doek! She made her foray into writing eight years ago when she landed in Romania. She learned her writing craft through blogging and newsletter editing. Her fortes are travel and memoir writing.