Ode to a (dead) cocaine patient

I haven't written for a while. Sometimes I wonder if the long daily hours of being a care giver in primary care may make me jaded. 'Just another day in the office...' so nothing to write about.

On Wednesday evening, as I was winding down paperwork before the Thanksgiving holiday, I got a text message from our Nurse Practitioner covering the phones. The police had called and asked if I would be willing to sign a death certificate on one of my patients. She had been found dead in her apartment with a crack cocaine pipe beside her and foaming at the mouth.

As I put the phone down, I replayed in my mind the first time I met T. She looked older than her stated age, was edentulous, only partially dressed. She shook her hands and yelled, "Help me! Help me! The pain, doc! I can't stand the pain! My hands are burning!" She would sob and cry and shake her hands. Occasionally, she let out a loud expletive. I saw that she had a fleshy mass with a slender stalk attached to her front maxillary gum line. She did not know what it was. She complained of feeling hot and 'burning up' and began to take off her clothes till she stood almost naked before me. I confess, I was overwhelmed with this new patient in an acute state.

I learned that she was diabetic and poor control had led to crippling peripheral neuropathy. She reported that neuropathic pain agents did not help her at maximum doses. She told me she resorted to cocaine because it made the pain bearable.

I remember prescribing her narcotics and getting her set up with a case manager and a social worker. The next time I saw her, she wore a wig, had come with a case worker and seemed calmer. Under local anesthetic, I excised the flesh mass from her maxillary gum line. She was surprised it did not hurt and pleased with the appearance.

Over the next few months, I watched her appearance transform as she felt we were making progress in her pain management and symptom control. She would come in with a wig on, make-up on her face, a set of dentures in her mouth, properly groomed and dressed. She would laugh and speak calmly. Although she was on a couple of narcotics, I felt we were getting somewhere. Her HbA1C began to improve. Her case manager helped her get into counselling, attend meetings to deal with her past.

I learned that T ran away from home at 16. Her maternal grandfather had been sexually abusing her. On bad days, she would cry in my office and tell me, "Doc! I can still see those hands in my dreams. His hands, doc! He would come into my room at night and put a hand over my mouth, and grope me and rape me. He told me that I told anyone, there'd be hell to pay." She ran away from home and became a prostitute. She became hooked on cocaine. She had a son and was now a grandmother. She raised a good boy, she told me.

There were ups and downs. She had several admissions for delirium, psychosis and respiratory failure due to overdoses with cocaine. I discontinued the prescribed narcotics. The old T came back: "Doc! The pain! I can't bear the pain! Give me something, doc! Give me something for pain!" I had nothing to give her that would work.

After her last hospital stay, she had enrolled in an addiction program. She had promised me that she was done with cocaine. She wanted to live for her grand-daughter, whom she loved. I would see her every month and haltingly, she seemed to be coming along.

Until the text message. T is dead. Anger welled up in me as I attempted to address the needs. Yes, of course, I would sign the death certificate. Yes, goodbye.

Who killed T? Was it the maternal grandfather that raped her repeatedly till she ran away from home? Was it the predators in society who took advantage of a young black girl's body? Was it the pushers and pimps that turned her onto cocaine? Was it a system that could not provide her resources to manage her diabetes? Should we hold T responsible for 'poor choices'?

Yes, officer, of course I will sign the death certificate. Yes, thank you. Have a good Thanksgiving. Goodbye!