24 hours in Philadelphia’s opioid epidemic at Episcopal Hospital

Editor’s note: Medical students from the Lewis Katz School of Medicine at Temple University spent 24 hours recently at Episcopal Hospital in Kensington, at the heart of Philadelphia’s opioid epidemic. They chronicled a full day in this corner of the most deadly big-city drug crisis in the United States, which took more than 1,000 lives last year. The project introduced first- and second-year students to addiction medicine, people suffering in addiction, and the medical professionals working to save their lives. Here are excerpts of reflections from that day. Read the full version here.

Medics had picked him up off the street, covered in his own vomit.

The Emergency Department 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 underwhelming.

His breathing is agonal — slow, labored. Medical assistants remove his seemingly endless layers of sweatshirts over T-shirts.

The doctor orders a nurse to give him Narcan to revive him. When he wakes, he is agitated. So she orders a benzodiazepine to calm him. Soon, he rests peacefully.

A nurse comes in to bag up his clothes.

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

“He just had the one,” the doctor replies, as if that were perfectly normal.

The doctor crouches by the head of the patient’s 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.

“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 out to gently wipe under his eyes.

My life in medical school revolves around grades and tests and feels as if everything has become a competition. As I walk into the Crisis Response Center (CRC) — where 13,000 people with mental illness and, often, substance-use issues come every year — I am struck by the total calm. A few people in the waiting room are wrapped in blankets; many are sleeping.

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.

“How are you feeling right now,” asks the psychiatry 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 about his drug use, then three last questions:

“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.

We see more patients, and for the next three hours, I forget about the grades that define my life.

I realize that I am losing my grasp of the part of myself that wanted to go to medical school. 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?”

A bearded man is trying to pry open the automatic sliding door of the Emergency Department. A doctor tries to convince the man, brought in after an overdose, to stay. A nurse tries to find his 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.

Not 30 minutes later, he 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 Avenue. I’m impressed that he was able to leave, purchase heroin, get high and return, all so quickly. The doctors don’t seem surprised.

The shaggy-bearded young man with blue eyes, in a faded hospital gown and mismatched socks, told me that he started with marijuana when he was 12 years old, progressing to cocaine and opioids by 18. He currently uses heroin and fentanyl.

He was homeless, depressed, and infected with both HIV and hepatitis C, hospitalized many times for complications 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 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.”

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

- Miranda Haslam, Kurt Koehler, Caroline McGillivray, and, Aron Stark

―

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

Underneath layers of sweatshirts and hats was an elderly woman. Tears welled in her big brown eyes.

She talked about how badly her husband and son wanted her to stop drinking.

“We can help,” said the doctor.

I could sense the woman wanted help. But 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.

After she left, the doctor listened to her sister 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 that seems impossible to fight.

The third patient I saw was young, homeless, and in crisis.

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

“More than 10 years,” he replied, but insisted he wanted to “get better.”

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

The patient was not taking anti-retroviral drugs prescribed for his HIV, and that meant he could not be admitted to inpatient addiction therapy.

We made an appointment for him to get his HIV drugs, but he seemed overwhelmed. “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.

The CRC helped me understand how 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.

An older man who had been on the sixth floor for two days talked with me at length about his life. When I asked about opioids, he let silence fill the room. Finally, he said, drugs just let him ‘feel like a kid again.’

I thanked him for his time. A nurse wheeled him out the door.

Just about weekly, he comes to the hospital, typically overdosed on heroin. This time, paramedics found him on the street, without any clothes. The hospital gave him the gray crew neck sweater he left in, along with some other clothes. He was taken to a shelter.

I realized there is no single image or stereotype of what a person with substance abuse disorder looks like. This man just wanted his story heard, and I was grateful to have listened.

“Well I hope you’re still staying with us,” the recovery specialist said to his white-bearded patient as he walked 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 emergency department, 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, living proof that it’s possible to break the cycle of addiction.

I went through a metal detector to get to a locked door leading to a locked elevator to a locked floor. 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 a few hours at the hospital, listening to patient stories, so energized to be in a clinical environment, I drove past “Emerald City,” the Kensington encampment where many people struggling with substance use disorder lived until police cleared the area recently. Snow was 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.

As a doctor working in a busy emergency department, having students with me was both motivation and looking glass. I 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 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 imparts strength.

A morning or afternoon shadowing a doctor is woefully insufficient to understand the complexity of addiction and its intersection with hospital medicine. And yet, it took the first student far less than one hour to understand something of the loneliness, desperation, and despair that drives two Americans in their 30s to Bed 8 — one in the bed and one crouching beside it.

- Katya Ahr, Neena Kashyap, Kelsey Muir, Ambuj Suri, Daniel Yusupov, and Naomi Rosenberg, M.D.

―

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 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.”

The hospitalist 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 gain strength by saying no to heroin so that she could finally beat it. But she had come in after an overdose.

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

A woman told us she had injected heroin a few days earlier, and the needle broke. It was still in her neck, and now she had an abscess growing around the needle fragment.

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.

The patient emphasized that so many of the people she’s met in Kensington had good lives. Addiction, she said, is the demon.

Sitting in a corner of the Crisis Response Center waiting area, a hospital blanket pulled over his head, our next patient emerged only when he was called into a small examination room. He still clutched the blanket, pulled up to his neck.

”Can you tell me why you’re here?” the resident asked.

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

The resident repeated the question, raising his voice just enough to get the man, fresh off being revived from an overdose, to open his eyes.

“I have an addiction,” he said.

I was struck by his honesty. His eyes closed again and that was the only history we could get.

The attending physician, his resident, and a nurse were standing around a stretcher in the hallway. On it lay a young woman, barely conscious. “She’s dying,” the doctor said.

He slipped on a pair of green, sterile gloves and deftly inserted an IV into the right external jugular vein of her neck to quickly deliver the medicine she needed to live.

In another hallway bed was a man found by an ambulance crew just a few blocks from the hospital. His heroin overdose was less severe and allowed a more gentle approach to treat it – a warm place to wake up, a nasal cannula to support his breathing.

When this patient felt better, he agreed to speak with me. He didn’t say how long he’d been using heroin 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. Any 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.

They showed me that at least some part of them thinks it may not be impossible to beat this.

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 words like milligrams and deciliters.

I lost my bearings entirely when the resident started to ask a patient how much of each drug he was using. 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. I envisioned bars of gold in an old-time heist movie. A bar of Xanax is in fact the size of a Tic-Tac and means a two-milligram dose.

This patient had brought himself to the Crisis Response Center 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.

- Amanda Foote, Connor Hartzell, Katherine Ortmeyer, Vered Schwell Eileen Storey, and Michael Vitez

―

“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 more than 100 patients and 24 overdoses in one 8-hour shift. The reason was a bad batch of heroin that had been mixed — without the users’ knowledge — with stimulant drugs. It was 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, describing patients 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?

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

I ask the patient why he uses PCP. He tells me that nowadays it gives him peace of mind, keeps him calm, awake.

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 can hear the remorse in his voice.

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

“I’m tired,” he whispers.

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.

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.

The patient was only a bit older than me. He had tattoos and scabs on his arms and hands. The scabs were also on his neck where he admitted to 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 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 he immediately felt “all was right.” He wanted more. An injury led to a surgery and with that came his first Percocet. He convinced his physicians to give him more Percocet than he needed. He does not blame them for giving him what he wanted.

Eventually the Percocet led to heroin and fentanyl. He burned 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.”

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, so I thanked him 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.” I was sad that I hadn’t used his name.

He had come because he could not sleep. He had been having hallucinations, unable to go to classes. He had prescriptions for a very high amount of Adderall and for Xanax.

Adderall is an upper, while Xanax is a downer. By his account, the combination 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 Crisis Response Center.

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

I thought this patient must be an example of exactly what she meant.

“I ain’t no fool,” says a man who sits in the wheelchair in the Crisis Response Center. “I’m just in bondage with the devil.”

His family brought him to the CRC after he was talking about killing a man who beat him. He considers himself a protector of his neighborhood, and not “a crackhead,” simply a smoker.

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.

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

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, his 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 told me they hadn’t even talked about pain management yet, just that the patient would need another appointment to get an MRI of his shoulder.

The doctor talked with me 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. Or perhaps negative experiences with doctors in the past primed the intensity of his emotion. I would never know.

- Angela Battaglia, Anthony Bernick, Roshni Bhat, Joe Corcoran, Phil Delrosario, Pablo Gutierrez, John Lasky and Will Schifeling