Privileged: the undertaker and me in the middle of the night

It was the night after Thanksgivings about 1 am when I received the call from the acting medical examiner. The county employed only one ME at that time.  He was a senior physician who had cut back his clinical practice and he was off for the holiday weekend. The physician covering the job that night was a distinguished gastroenterologist, the first in the county to remove a gall stone lodged in the pancreatic duct with an instrument he passed down the esophagus, through the stomach and into the pancreatic ducts.  He had traveled to Japan about five years earlier to learn the technique before gastroenterologists at major academic medical centers began teaching this to their trainees. I had learned of his unique expertise  soon after my arrived in New Jersey over three years earlier. That night I learned that his technical skills were driven by his concept of conscientious and responsible professional behavior.

My wife and I were sleeping in the first house we own in Piscataway. The hospital operator had given the acting ME my number. I awoke on the phone as the acting ME spoke in his distinctive German accent. The police had informed him that one my patient died in his son’s presence earlier that night.  The ME had an obligation to further investigate this death by ordering a post mortem examination if the death was not certified to be of natural causes.  

The acting ME wanted to tell me that someone had to go to the deceased’s apartment before the undertaker could remove the body---someone who knew the patient, his medical background and mood; someone who would understand the reasons for the patient’s death. That someone he said “is you because you were the patient’s doctor.” The acting ME continued: “You do not want the emergency medical technicians and ambulance people to get up in the middle of the night to remove the body to the hospital simply for our convenience. These individuals are volunteers who donate their time to transport the living and what would they think of doctors who ask them to transport the dead in the middle of the night on a holiday weekend?”

In my fourth year as an attending physician, I was not about to argue with the acting ME. I simply asked for the patient’s address, dressed immediately and set out for the neighborhood in Plainfield to inquire, pronounce and certify my patient’s death.

As I drove I began gathering my thoughts about Mr. Kelly.*  I thought of his life as a former alcoholic who was treated for TB. He was retired and living with his thirty plus year old son in a mutually dependent relationship. Mrs. Kelly was never in the picture suggesting that the patient’s former alcoholic lifestyle must have destroyed his marital  relationship.   His son always accompanied his dad to my clinic. Mr. Kelly had been hospitalized when I initially saw him for profound weakness, weight loss and debilitation. With his past history of TB which can affect the adrenal gland, you did not have to be a medical mastermind to consider adrenal insufficiency as the cause of his illness.  When I made that diagnosis and gave him cortisone, he enjoyed a remarkable health renaissance. As I drove to his apartment, I thought “Why did he die suddenly?”

When I reached the address on a commercial street with apartments above retail stores, a black station wagon, the undertaker’s vehicle, was parked just ahead of me in front of the building. The name plate in the back side window indicated this was a well established funeral firm. The building door was open and I climbed the dark staircase in this firetrap of an edifice to the third floor. The undertaker was outside the open apartment door in the hallway at the top of the staircase. He was about twenty years old. His last name was the same as that of his firm.  He was the youngest member of the family business!  Mr. Kelly lay on a sofa in the small dark unkempt living room, quite dead and already cold. His son was sobbing sitting nearby. 

The son said that when his dad returned home in the late evening from a Thanksgiving trip to upper New York state, he was very weak and vomiting. Mr. Kelly had left the apartment Thanksgiving morning and forgotten to take his cortisone drug with him. He had been drinking again to celebrate Thanksgiving the evening before. He had been sick all day but decided to drive home.

This history suggested that it was a miracle that Mr. Kelly was able to get home alive but a tragedy that he did not drive himself to an emergency room first, where he could have been saved by an injection of intravenous cortisone.   His weakness was so profound that his son had to drag his father up the stairs. His abdominal pain and vomiting were typical of acute adrenal insufficiency. He fell onto his parlor sofa and probably died of low blood pressure characteristic of adrenal insufficiency.

The son was attentive to his father and I could not conceive of him being devious enough to make up this story.  He was not the type of person who could poison his daddy;  nor was he an able enough actor to be playing a role as a bereaved son.   I went down to a street phone to call the acting ME as there was no phone in their apartment.  I apologized for awakening him at 2:30 am to tell him that I did not think a post mortem exam would be more informative than what I recognized already.  I thought it appropriate to release the body to the undertaker if the ME agreed. I would certify that the cause of death was natural secondary to adrenal insufficiency.  The ME was pleased and immediately ended our conversation.  

When I returned to the apartment, the young undertaker was sitting next to the son trying to console him. He asked if a priest would be helpful. The son did not disagree.  So the undertaker went to the same street phone which I used and called a thereby parish. When he returned, he told me that a priest would not be visiting. Because we were two flights above the street, the undertaker, the son and I toiled to bring the body down the stairs to the station wagon. Once Mr. Kelly was secured in the back of the wagon, I asked young Kelly if he would be all right. When he said he was okay, I shook hands with him and told the undertaker where to pick up the death certificate. I thanked him for his help. We all parted at the curb. I arrived home at dawn, thinking that the world was still asleep as the undertaker and I did our job that night.

Twenty-five years later the physician who was acting ME that night came to me as a patient with one of the most profound diabetic neuropathies I had ever encountered. He was addicted to narcotics to relieve pain. He asked me to help him detoxify from narcotics while treating his neuropathic pain. I told him I was not qualified to use methadone. He said I underestimated my reputation and that the medical board would understand that I was prescribing methadone appropriately and ethically. I undertook that challenge and his care and recovery was one of the most privileged experiences of my career. 

*not his real name

What’s killing to our fabulous performing artists?

Elvis Presley, Michael Jackson, and most recently, Whitney Houston:  all died prematurely with toxic substances in their system.  Did they ever hear of Marilyn Monroe, home, alone with a bottle of barbiturates on a Saturday night?  The death of each of these gifted people and many more creative artists from alcohol and drugs are a loss of unique talents which extend the bounds of human nature.  Their extraordinary gift brought them fame and wealth. Why did they have to succumb to substance abuse?  What goes wrong? What were their doctors doing?     

I have not been privileged to treat the Whitney Houston’s of the world in my career.  But I have cared for many individuals who dealt with inordinate professional and personal stress in their lives and continued their high octane performance without needing drugs to cope.  These are men and women from all strata of our society and include clergy, senators, judges, deans, chair persons, scientists, professors, teachers and master physicians. I saw the difference between these admired and accomplished people and others who were addicted to drugs.  

I had plenty of experience with drug abusing patients. I am the product of inner city hospitals:  Newark’s Martland Hospital, the Jersey City Medical Center and the East Orange Veteran Administration Medical Center of the riotous 1960 era when I was a medical student.  I further trained at Kings County Hospital Center in Brooklyn and the Bronx Municipal Hospital Center.  The Battle of the Bronx was so intense and demanding in the early 1970’s that the Albert Einstein Medical School, which oversaw my education, was able to defer my 1A draft classification to work in the Bronx rather than in Viet Nam.  I cared for patients with the complications of alcohol and cigarette addiction, the acute flooding of blood in the lungs caused by heroin overdose and the deep coma of patients with barbiturate overdoses or suicide attempts.  I cared for many patients with the complication of intravenous drug abuse which results in hepatitis, heart valve infections, AIDS and other esoteric infections.

I am indebted to these patients who helped me develop my skills as a physician. How do they differ from my well adjusted patients?   I often observed the absence of enriching interpersonal relationships in these patients who needed love more than others. Their childhoods were predictably chaotic as their parents were usually unstable.  Chiefly the patient had an inability to suppress the hedonistic or pleasure seeking impulses of the brain. Together these brought the patient poverty in circumstance, body and mind.  

I recall a patient who required heart surgery to replace his infected aortic heart valve, caused by his habit of giving himself intravenous narcotic injections. These patients routinely reuse and share their needles which cause them to contaminate themselves.    After a successful operation, he returned to the hospital several months later, again with an infected aortic valve. He had resumed injecting crack, a combination of heroin and cocaine.   I asked him:  “Why?  Wasn’t one near death experience with your first infected heart valve, enough of a warning that this might kill you.” “Doctor, you have no idea of the stress I experience.”   I had to treat him again to clear the infection and convince a heart surgeon to insert another aortic valve.  I turned to the resident physician in training who was caring for the patient with me.   I said: “You are working over 80 hours a week. You work with 20 patients a day.   You have to make 100 right decisions a day to care for them. Why are you not taking drugs to cope?”    He was then 27 years old and has gone on to have an exceptional career as a physician’s physician in Princeton, NJ.  He said:   “I have been prepared to handle stress.”

That preparation began in childhood.  His parents taught him that he was special but that he was still govern by the rules of healthy living.  He had to keep his body strong and fit to deal with the challenges of his education, his relationships and ultimately his work.  He can not disappoint the family who gave him their values with love and support and will be there to help him.  He did not need drugs to suppress the stress of dealing with new situations or to give him moments of pleasure.   As he overcame his educational hurtles, he grew in confidence and self esteem and he became capable of dealing with increasing responsibilities until he was independently in charge of his patients.  He kept sight of the big picture:  staying healthy and maintaining his interpersonal support.  Why put his mental acuity or body at risk with mind boggling drugs though these are more readily available to him in purer forms than to the patient on the street?  There is nothing free of consequences.    

If a resident physician in training realizes all this and knows why he is succeeding, it is puzzling why the doctors who provide drugs to our fabulous entertaining artists have not counsel their patients to preclude their killing themselves with substance abuse.  These artists are special people too but they are human and the rules of healthy living apply to them like the rest of us. Their families, friends cannot stand by and let them ignore these rules and trust doctors who treat with unlimited access to potentially harmful drugs.

We do not know the details of Whitney Houston’s problems but she appeared at times to be anorexic.  Drugs are generally poorly effective for weight problems. She might have benefited from behavioral counseling done very frequently in which the therapist worked on her insight and motivation and simply tried to develop in her an aversion to self destructive hedonistic impulses, like taking cocaine. In the last moments of her life, Ms. Houston craved a “high” from that agent but instead the drug constricted her coronary arteries which it often does. Her heart became weak and she collapsed into a full bathtub and drowned.  Ironically she was in one of the most beautiful neighborhoods in the world on a Saturday afternoon.  Instead of taking alcohol and cocaine into the bathroom, she might have learned through counseling to avoid risk. She could have said to one of her companions.   “Let’s become inconspicuous and let’s take a walk down Beverly Boulevard where there are some of the most beautiful houses in Beverly Hills. Let’s go to the park down the street and watch the kids play in the sand and the old men play bocce.  I might want to talk to a few fans.”  Can you image the mutual thrills and adulation she would receive in that little park?  That would be a high greater than any provided by cocaine.  If she took that walk in the sun that afternoon with her friends, we might still be enjoying the sound of her genius.  

What is killing our fabulous performing artists?

Elvis Presley, Michael Jackson, and most recently, Whitney Houston:  all died prematurely with toxic substances in their system.  Did they ever hear of Marilyn Monroe, home, alone with a bottle of barbiturates on a Saturday night?  The death of each of these gifted people and many more creative artists from alcohol and drugs are a loss of unique talents which extend the bounds of human nature.  Their extraordinary gift brought them fame and wealth. Why did they have to succumb to substance abuse?  What goes wrong? What were their doctors doing?     

I have not been privileged to treat the Whitney Houston’s of the world in my career.  But I have cared for many individuals who dealt with inordinate professional and personal stress in their lives and continued their high octane performance without needing drugs to cope.  These are men and women from all strata of our society and include clergy, senators, judges, deans, chair persons, scientists, professors, teachers and master physicians. I saw the difference between these admired and accomplished people and others who were addicted to drugs.  

I had plenty of experience with drug abusing patients. I am the product of inner city hospitals:  Newark’s Martland Hospital, the Jersey City Medical Center and the East Orange Veteran Administration Medical Center of the riotous 1960 era when I was a medical student.  I further trained at Kings County Hospital Center in Brooklyn and the Bronx Municipal Hospital Center.  The Battle of the Bronx was so intense and demanding in the early 1970’s that the Albert Einstein Medical School, which oversaw my education, was able to defer my 1A draft classification to work in the Bronx rather than in Viet Nam.  I cared for patients with the complications of alcohol and cigarette addiction, the acute flooding of blood in the lungs caused by heroin overdose and the deep coma of patients with barbiturate overdoses or suicide attempts.  I cared for many patients with the complication of intravenous drug abuse which results in hepatitis, heart valve infections, AIDS and other esoteric infections.

I am indebted to these patients who helped me develop my skills as a physician. How do they differ from my well adjusted patients?   I often observed the absence of enriching interpersonal relationships in these patients who needed love more than others. Their childhoods were predictably chaotic as their parents were usually unstable.  Chiefly the patient had an inability to suppress the hedonistic or pleasure seeking impulses of the brain. Together these brought the patient poverty in circumstance, body and mind.  

I recall a patient who required heart surgery to replace his infected aortic heart valve, caused by his habit of giving himself intravenous narcotic injections. These patients routinely reuse and share their needles which cause them to contaminate themselves.    After a successful operation, he returned to the hospital several months later, again with an infected aortic valve. He had resumed injecting crack, a combination of heroin and cocaine.   I asked him:  “Why?  Wasn’t one near death experience with your first infected heart valve, enough of a warning that this might kill you.” “Doctor, you have no idea of the stress I experience.”   I had to treat him again to clear the infection and convince a heart surgeon to insert another aortic valve.  I turned to the resident physician in training who was caring for the patient with me.   I said: “You are working over 80 hours a week. You work with 20 patients a day.   You have to make 100 right decisions a day to care for them. Why are you not taking drugs to cope?”    He was then 27 years old and has gone on to have an exceptional career as a physician’s physician in Princeton, NJ.  He said:   “I have been prepared to handle stress.”

That preparation began in childhood.  His parents taught him that he was special but that he was still govern by the rules of healthy living.  He had to keep his body strong and fit to deal with the challenges of his education, his relationships and ultimately his work.  He can not disappoint the family who gave him their values with love and support and will be there to help him.  He did not need drugs to suppress the stress of dealing with new situations or to give him moments of pleasure.   As he overcame his educational hurtles, he grew in confidence and self esteem and he became capable of dealing with increasing responsibilities until he was independently in charge of his patients.  He kept sight of the big picture:  staying healthy and maintaining his interpersonal support.  Why put his mental acuity or body at risk with mind boggling drugs though these are more readily available to him in purer forms than to the patient on the street?  There is nothing free of consequences.    

If a resident physician in training realizes all this and knows why he is succeeding, it is puzzling why the doctors who provide drugs to our fabulous entertaining artists have not counsel their patients to preclude their killing themselves with substance abuse.  These artists are special people too but they are human and the rules of healthy living apply to them like the rest of us. Their families, friends cannot stand by and let them ignore these rules and trust doctors who treat with unlimited access to potentially harmful drugs.

We do not know the details of Whitney Houston’s problems but she appeared at times to be anorexic.  Drugs are generally poorly effective for weight problems. She might have benefited from behavioral counseling done very frequently in which the therapist worked on her insight and motivation and simply tried to develop in her an aversion to self destructive hedonistic impulses, like taking cocaine. In the last moments of her life, Ms. Houston craved a “high” from that agent but instead the drug constricted her coronary arteries which it often does. Her heart became weak and she collapsed into a full bathtub and drowned.  Ironically she was in one of the most beautiful neighborhoods in the world on a Saturday afternoon.  Instead of taking alcohol and cocaine into the bathroom, she might have learned through counseling to avoid risk. She could have said to one of her companions.   “Let’s become inconspicuous and let’s take a walk down Beverly Boulevard where there are some of the most beautiful houses in Beverly Hills. Let’s go to the park down the street and watch the kids play in the sand and the old men play bocce.  I might want to talk to a few fans.”  Can you image the mutual thrills and adulation she would receive in that little park?  That would be a high greater than any provided by cocaine.  If she took that walk in the sun that afternoon with her friends, we might still be enjoying the sound of her genius.