There were red specks flying all over the table and floor— She was scratching off a lottery ticket when I walked in; her blue-glued nails picking off the rows and columns, revealing numbers in vulgar font. Jumbo Bucks in bold. Win up to 20 times. I sat down and as she scraped she cussed out the ER doctor whom she saw two days ago.
He wanted urine.We were in the hallway. She only used coke and it was more than two weeks ago. I have heard this story many times. If not hers others. What can I say? I can only understand what was documented. He wanted tests but you left AMA; this wasn’t the first time. You look at me— Your eyes titanic glaciers melting and breaking. You raise your left arm and stretch it in front me. They tried to pry open my veins. You felt it. You woke up and they were at your groin. I explain about veins. She knows but still. How ill? Very. You should have stayed. She turns and goes back to picking
numbers. I hate it when she comes late to our appointments. How many times has she scheduled a visit with me and no showed? I could stop prescribing her adderall. I can end this visit now and move on to the next patient. You tell me your mother is dying. You left to be with her. You were with her when they decided to send her home to die comfortably. Her legs became huge. Tree trunks. She groans in pain and her heart is all to shit, excuse me. I stop
looking at my computer. It was three years ago when I first touched your arms and legs— craters and valleys, an archipelago of scars and atrophy. You know about veins and you ran out of them. You stopped using years ago but new ulcers appeared and that’s how I came to know you. Finally, one day you let me biopsy them. The results showed a vasculitis and I planned for more tests. Your lungs became sick and one day you couldn’t breathe so I advised you to go to the ED.
You hate being here. We all have that ache of blood. You tell me you have been taking the train to Boston every day. Your mother lives there and now she is dying there— Your fingers stop moving. Silently you sit in this heavy corner of the room.
Sifting through the rows, you eventually find a plastic seat. Looking out at the moving trees through the window you remember how she held you while you were in withdrawal. How many rooms has she stolen you from; how many times has she sat by your lying body on the bed? You tell me you are the oldest child and the worst. Methadone saved your life but you must return here daily
to receive it. I push a little tissue box to you like an offering. We breathe and my slow hand reaches for your shoulder. We share about the sweetness of cautery; the hidden slaying. Heads down, hand on hand. We prayed for your mother and for ourselves— my blood cells flowing so close to yours.
Testing for drugs of abuse (DOA): Time frame for positive urine assay with acute exposure: amphetamine (1-2 days), benzodiazepines (1-5 days), cocaine (2 days), LSD (1-3 days), marijuana (1-3 days), opioids (1-3 days), methadone (1-5 days), PCP (4-7 days).
“Coke” – “Pure cocaine was first isolated in the 1880s and was first used as a local anesthetic in eye surgery. It was particularly useful in surgery of the nose and throat because of its ability to provide anesthesia and constrict blood vessels, thereby limiting bleeding. Cocaine was legal and widely used in the United States during the second half of the 19th century and was a main ingredient of the original Coca-Cola.”; Onset of action and duration of action for various routes of exposure: intravenous (<1 min, 30-60 min), nasal (1-5 min, 60-120 min), smoking (<1 min, 30-60 min), gastrointestinal (30-60 min, unknown).
Heroin – “The intravenous (IV) route is rapid and produces high bioavailability but is also most dangerous to the user. Injection is the most efficient means of producing euphoria when relatively low-purity heroin is being used. Most overdoses occur when heroin is taken intravenously.”
Against medical advice (AMA): “To persuade patients to remain hospitalized, 85% of trainees and 67% of attending physicians in one study incorrectly informed their patients that insurance will not reimburse a hospitalization if they leave AMA; Because all competent patients have the right to decline recommended inpatient treatment, the ethical and legal standard is that the physician obtain the patient’s informed consent to leave by communicating the risks, benefits, and alternatives to leaving and fully documenting the conversation in the medical record. The additional steps of formalizing the discharge as AMA and providing AMA forms for the patient to sign have never been demonstrated to improve quality (and add needless clerical work).”
Hypertrophic and atrophic scars: “One study that examined the pattern of addict-chosen injection sites found that the veins in the antecubital fossae are initially used; however, after 3 to 5 years, these veins become sclerosed and inaccessible. Other peripheral sites are then used for intravenous access, with the hands, neck, feet, legs, and dorsal vein of the penis having been described in the literature. A patient has been described who attempted venipuncture 50 times per day trying to find a patent vessel.”
Vasculitis – “is an inflammation of the blood vessels. It happens when the body’s immune system attacks the blood vessel by mistake. It can happen because of an infection, a medicine, or another disease. The cause is often unknown.”
Origin of “cell”: early 12c., “small monastery, subordinate monastery” (from Medieval Latin in this sense), later “small room for a monk or a nun in a monastic establishment; a hermit’s dwelling” (c. 1300), from Latin cella “small room, store room, hut,” related to Latin celare “to hide, conceal;” From “monastic room” the sense was extended to “prison room” (1722). The word was used in 14c., figuratively, of brain “compartments” as the abode of some faculty; it was used in biology by 17c. of various cavities (wood structure, segments of fruit, bee combs), gradually focusing to the modern sense of “basic structure of all living organisms” (which OED dates to 1845).
Methadone – “By the 1970s, the system for delivering methadone that we know today had been fully developed. Patients visit a designated clinic, typically every day, take methadone under observation, and get specialized, highly structured care, including counseling and periodic drug tests.”
Introduction to the Devout Life by St. Francis de Sales – “But so long as God’s Providence does not send you these great and heavy afflictions; so long as He does not ask your eyes, at least give Him your hair. I mean, take patiently the petty annoyances, the trifling discomforts, the unimportant losses which come upon all of us daily; for by means of these little matters, lovingly and freely accepted, you will give Him your whole heart, and win His. I mean the acts of daily forbearance, the headache, or toothache, or heavy cold; the tiresome peculiarities of husband or wife, the broken glass, the loss of a ring, a handkerchief, a glove; the sneer of a neighbour, the effort of going to bed early in order to rise early for prayer or Communion, the little shyness some people feel in openly performing religious duties; and be sure that all of these sufferings, small as they are, if accepted lovingly, are most pleasing to God’s Goodness, Which has promised a whole ocean of happiness to His children in return for one cup of cold water. And, moreover, inasmuch as these occasions are for ever arising, they give us a fertile field for gathering in spiritual riches, if only we will use them rightly”
The Interior Carmel: The Threefold Way of Love Hardcover by John C.H. Wu – “They are mistaken who say that we are mercenary workers, because we talk of reward. They should know that the reward we are hoping for is not extrinsic but intrinsic, for it consists in the union with the Source of our being. A lover is not mercenary when he desires to be united with the object of his love. Nor can a fish in shallow waters be said to be a mercenary fish when it yearns for its home in the deep”
Cauterization – (or cauterisation, or cautery) is a medical practice or technique of burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, or minimize other potential medical harm. (In clinic we use electrocautery at the bedside to stop a particularly problematic vessel)