The One Who Got Away
Tim’s angels were always brighter than even his fiercest demons. Although he was my patient for many years, this is his story.
Tim was, hands down, the nicest person I ever met. Married and in his early thirties, Tim worked as a car salesman at a local dealership. He had won “Most Valuable Employee” five years in a row. Armed with a consistent, quiet calmness, a dose of curiosity, sandy blonde hair and a radiant smile, Tim was universally beloved by everyone in our office. He was even on a first name basis with the cleaning staff. Patients and staff alike looked forward to his attendance at our weekly group therapy classes. He was one of those truly unusual people who was always kind… just to be kind. No expectations of anything in return.
Tim also struggled with substance use. More so than most. A few years prior to entering my world, he was introduced to opioids by a boss who exclaimed, “Tim! You are my best employee! Customers love you. You should work with us seven days a week instead of five days a week. Here, this pill will give you even more energy and calmness.” And thus his troubled relationship with opioids began.
Although he was prescribed Suboxone from me to help reduce opioid cravings and substance use, Tim’s urine drug screens were often positive for illicit substances. The Suboxone helped to reduce his frequency of illicit drug use, but it did not eliminate use altogether. It’s tempting to get frustrated with this as a provider. But Tim was always honest and apologetic. He never blamed anyone else for his substance struggles. He would often start our appointments by calmly stating, “Well, Dr. G. I f-d up. Please don’t be mad.”
Despite his own struggles, many patients in our group addiction class attributed their own sobriety success solely to Tim. One guy remarked, “He made me believe I could do it when even I didn’t think I could.” Another commented, “He saw goodness in me when all I saw was despair.”
One gloomy Friday afternoon, I saw Tim standing in our building’s pharmacy pick-up line on the first floor. He did not see me. The line was about twenty people long. It was pouring down raining outside with large, grape sized droplets. Tim was nearing the front of the line. Judging from the length of the line, he had been waiting at least thirty minutes. One glance at him and I could tell he was in severe opioid withdrawal. His face was covered in sweat. Prominent goose bumps dotting his arms and legs. The phrase “quitting cold turkey” comes from the observation that opioid withdrawal causes body-wide goose pumps that pimple the skin, much like a fridge stored turkey.
He was pacing with a subtle but distinctly noticeable anxiety. He tapped his dripping umbrella nervously with his right index finger, which had a noticeable tremor. “Kicking the habit” comes from the observation that prominent tremors and enhanced knee reflexes occur with acute alcohol and opioid withdrawal. He looked really uncomfortable. Other common opioid withdrawal symptoms include diarrhea, muscle pain, nausea, and vomiting.
Since Suboxone contains a small amount of opioid, physical withdrawal can occur if people miss just a few days of their dose. Tim often worked very long hours at the car dealership. Because of his demanding schedule, he would frequently pick up his medication several days late. Today was no exception.
Directly behind Tim in line stood a young mother, bouncing a rowdy toddler on one hip and gently pushing a stroller with a sleeping infant in the other. Behind the mother stood an elderly man with large earnest eyes, anxiously leaning forward with his tall black curved cane, as if to physically will the overwhelmed pharmacist to work faster. Behind the earnest elderly man stood a younger man teetering on crutches. He fiercely clutched the crutch handles on either side, while positioning the edge of his paper prescription in his mouth. Behind the counter stood one frantic looking pharmacist, holding a phone in one hand while peck typing with the other.
Tim finally reached the front of the line. He looked at the pharmacist, then glanced back at the toddler toting mother. I saw him motion the mother to go ahead of him. Both hands now had pronounced tremors. The pharmacist belted out “Next in line!” Tim once again paused. He glanced back at the elderly man. By this time, the older gentleman was leaning so far forward it looked like he might topple over at any moment. Tim smiled at him and weakly squeaked out, “After you, sir.”
This continued with crutches guy. While the man on crutches was at the pharmacy window, Tim suddenly lunged towards the nearby trashcan. He barely made it before he began profusely vomiting. Folks near the front of the line looked on with a mix of sympathy and disgust (but mostly the second). I continued watching.
After obtaining his Suboxone prescription, Tim slowly walked towards the building exit. He clutched his stomach with his left hand ever so slightly, likely still quite nauseous. By this time, the rain was pelting down even harder. It was so thick you couldn’t even see the nearby cars in the parking lot. The toddler-infant toting mom exited from the bathroom at the same time Tim reached the front door. As she approached the exit, toddler mom stopped and starred at the rain. She looked down at her peaceful sleeping infant, and then back out the door with trepidation. As a fellow mom, I’m sure she was debating between two equally dismal options: Make a run for it now while drenching and waking the baby or wait it out and hope that my toddler stops screaming in the meantime and doesn’t need another diaper change. Both were bleak possibilities.
Tim took one look at the young mom and said, “Please, take my umbrella.” He could have offered to share it with her, but likely made the calculation that the mother would be uncomfortable sharing an umbrella with a friendly looking but nevertheless unknown man, covered in sweat and wearing a puke-stained t-shirt. A look of instant relief swept across her young, worried face. She smiled and simply said, “God bless you,” while quickly dashing out the revolving door and holding the umbrella to shield the sleeping baby. Tim ventured out behind her into the gray, flooding abyss.
Three months later, Tim was in a terrible car accident. It was a single car collision into a tree. The accident totaled his car and shattered three vertebrae. Although he could still walk, he now had to wear a bulky back brace. He was dependent on others for transportation. The consulting surgeon scheduled him for mandatory corrective back surgery. The surgery date was two months away. The surgeon also prescribed heavy narcotics to dull the now constant pain.
Single car collisions are usually due to distracted driving (texting), falling asleep behind the wheel, or alcohol/substance use. In Tim’s case, I suspected substances. But I didn’t have time to talk with him about the details of the accident. I was too worried about another, more pressing issue. Tim was now taking very powerful, prescribed opioids and benzodiazepines around the clock, in addition to periodically using other illicit substances. This is super dangerous.
When I saw the opioid/benzo regimen prescribed by the surgeon, I paged him immediately. “We gotta move this surgery date up. This guy won’t make it for two more months,” I explained. The surgeon sighed and said, “Lauren. The fractured vertebrae won’t kill him overnight. It will be uncomfortable, but manageable. You know how many hip replacements I have scheduled before him? He can get in line with everybody else.” “No, I get it,” I continued.” “The injury won’t kill him. But using heroin daily on top of it will.”
There was a slight pause. Then, in a very dry, matter of fact reply that only a surgeon can deliver, he said, “Well, that’s easy. Just tell him to stop.” I rolled my eyes. I took a deep breath to quell my frustration, then replied politely, “Dr. Smith. It’s not that easy. I left my magic wand at home today. Tim knows that combining the medications you prescribed him with heroin can be deadly. I’ve reiterated that to him several times. But addiction is a very powerful disease that often defies reason and logic.”
There was another pause. I could hear Dr. Smith’s pager buzzing in the background. He too was frustrated, and on the fence. Thinking quickly, I threw in, “If you bump him up, I’ll put in a good word for you with Dr. Litts.” Dr. Litts was our head physician in chief “boss.” Also, a headstrong surgeon herself, it was well known that Dr. Litts frequently butted heads with Dr. Smith. They were currently in a heated argument about when the surgery autoclave machines would be fixed. He finally muttered, “Ok. Ok. I’ll see what I can do. But no promises.” Then I heard the dial tone.
Three days later, I received a short but succinct page back from Dr. Smith: “Your patient’s new surgery date is eleven days from now. Best I could do.” I was pleasantly surprised. And hopeful.
But as the days drew closer to Tim’s surgery, I grew increasingly worried. Heroin use combined with high dose, prescription opioids and benzos is often fatal. I talked with Tim about my concerns almost daily. “Don’t worry, doc. I got this!” He assured me. “Thank you so much for getting that surgery moved up. I feel like a new man! And my boss says thank you, too,” he added. That boss can go to hell, I thought. But I merely replied, “Hang in there, T. You are almost there.”
The morning of Tim’s surgery was a busy, crisp Wednesday in October. The first leaves were changing colors and just starting to fall. There was a new chill in the air. At 8 am, Dr. Smith paged me. All it said was “Call me.” I felt queasy.
Dr. Smith picked up on the first ring. He started right in. “Tim did not show up for surgery. My nurse called his employer, who is listed as his emergency contact. They said Tim’s wife found him dead in his house yesterday. Am I in trouble? Will they sue me? What about the Board?”
In my mind, Dr. Smith’s voice began to sound like those high-pitched cartoon voices. I tried to bring my attention back to his continued questions, but it all became a blur. My vision narrowed. My breath quickened. I started sweating. I was suddenly sad and mad and overwhelmed all at the same time. I was mad at the surgeon for giving him the pain meds in the first place. I was mad at the system for not moving his surgery up even sooner. I was mad at myself for not doing more. Most of all, I was mad at Tim for leaving the world too soon.
I hung up on Dr. Smith and walked straight down to Theresa’s office. Theresa was Tim’s therapist. She was eating a breakfast muffin at her desk while chatting with another therapist who stood nearby. She chuckled at something the other therapist said while sipping her coffee. I just stood there and starred. She turned her head inquisitively towards me.
“Tim is dead,” I said. No preface, no context. No lead in. The tears were building up behind my emotional fortress, which was about to burst. Another word more and the damn would bust open. The therapist, as if she had just been shot, visibly jumped back. “What? Why?” she pleaded. Across her face flashed a look of shock and disbelief. I just turned around and walked away. I couldn’t muster anything more.
The following summer I took a cruise to the south of France and Italy. One day, my husband and I took an electric bike tour along the rocky southern shoreline of southern Italy. The lush mountains collided with the blue sky and the bluer ocean all at the same time. It was breathtaking. But oddly, the more perfect it became, the more I thought of Tim. To this day, I’m not sure why. But I think, maybe it was magnitude of the realization of how perfect and how perfectly heartbreaking this world can be all at the same time.
A few months after the cruise, on another crisp fall morning, my husband and I were signing mortgage documents to refinance our house at a lower interest rate. (As a frugal money guy, refinancing our home to lower interest rates was my husband’s favorite hobby. He looked forward to the entire process almost as much as he anticipated the Masters.) The young woman navigating the paperwork with us was bubbly, talkative, and energetic. She had dirty blonde hair and a broad smile. As we started the signing process, she began with the typical small talk: “How are you liking the change in weather? What led you to refinance? What do you do for a living?” She chattered on with a likeable, earnest, cheerleader-like zest.
When people ask what I do for a living, I often give a vague response like “healthcare.” Anything more specific often leads to more questions than I have energy to answer. For some reason, this day I ignored my usual self-imposed rules of engagement. I liked the friendly blonde. She reminded me of myself. She also seemed strangely familiar. Her talkative mannerisms, her warm smile, her pool blue eyes. In Psychiatry the term “positive countertransference” refers to having positive regard for someone because they unconsciously remind you of someone else from your past. “I’m an Addiction Psychiatrist,” I responded.
The lady stopped turning the document pages. She turned away. Her bottom lip trembled ever so slightly. Tears quickly flooded her pale blue eyes. Without saying a word, she stood up suddenly and fled to her back office. My husband and I starred at each other silently, both equally perplexed. After about thirty seconds she returned. She straightened her pink blouse and apologetically responded, “I’m so sorry about that. My brother died from an overdose last fall. We were close.”
I felt my pulse quicken. It couldn’t be. We continued signing page after page while I tried to muster the nerve to ask the most important question. In my heart, I already knew the answer. I just wasn’t sure I wanted her to confirm it out loud. “What did you say your last name was?” I asked, hesitantly. My voice cracked. When she said Tim’s last name, it was me who starred silently. Sensing something was off, my husband jumped in and carried the rest of the conversation. I don’t remember much else from the rest of the day.
I’ve seen Tim’s sister several times around town since that day. And this is my ethical struggle: I so badly want to tell her how wonderful he was, how brightly his light shown on others, how many other people he helped, and how hard he fought to beat the battle of addiction. But how do you talk about someone’s angels without revealing their demons? As a physician, my promise to protect patient privacy extends through death. At the same time, most of me thinks that Tim would be ok with me telling his family how much he meant to the rest of the world. But that’s not my decision to make.
What would you do? Several more years have passed by now. I still think of Tim every time I pass by a car dealership. Privacy ultimately prevailed. I never shared my side of his story with his sister. I guess the next best thing I can do is share it with you.