The Box

One of my responsibilities as chief medical resident is to host a monthly autopsy conference, where we tease out the admission details and formally present the case. The pathology resident then presents the details of the autopsy, including whether the original diagnosis was correct, any clues that could have been used to make different decisions during management, and the histology-proven cause of death. These cases can be some of the toughest we encounter. The case I was presenting wasn't a mystery. To be honest, I had no idea why my pathology colleague chose it. A white man in his 30s with a history of heroin abuse presented to the ER with obtundation and a respiratory rate of 6. Naloxone revived him almost instantly, but his breathing status worsened. He was intubated and sent to the ICU with opioid-induced pulmonary edema. He continued to decline against extraordinary measures. As the decision was being made to transfer for extracorporeal membrane oxygenation, he coded; 22 minutes later, he died. This was sad. But it was sad like news of a hurricane 3000 miles away. It would have been nice to have saved this man's life, but this happens all the time across the United States and especially here in the Ohio River Valley. Our police empirically administer naloxone to people they can't arouse on the street. One police officer in the trauma bay told me that some strip clubs have their strippers carry naloxone at work because customers dying is bad for business. I opened the chart, pulled out the template, and started filling in the slides with the clinical information. I read the death note, always jarring when the patient is in his or her 30s; some nursing notes; and the H&P. Another drug user. Clich. The surgical history was unexpected, though: a recent repair of the left tibia and femur earlier in 2017. He had been in a car accident. I found that H&P. He apparently was walking with his children near his house when a drunk driver jumped the curb and swiped him. His children were spared, and he ended up with a broken femur and tibia. One exceptionally well-written medical student note said he was faithfully attended to by wife and children. He spoke of his children and playing in the backyard, his love of his family, and how he just wanted to get stronger and finish rehab so he could get back to his life. Throughout that hospital course, notes reference a dad playing with the kids in his hospital room and a wife cheering him on during therapy. I double-check to make sure the EHR hadn't put me into someone else's chart. The discharge note had one medication5 mg of oxycodone every 6 hours as needed for pain, with a caveat: 7 days, then deescalation to Tylenol or NSAIDs. This didn't happen. I accessed our state's opioid-monitoring system and saw that someone kept giving him the oxycodone; the clinic notes show it. His wife stopped coming to appointments with him. Two months in, he was labeled a drug-seeker. He was lost to follow-up. A public search showed he got divorced. A month later, he died. I presented the case exactly as I wrote this essay. The audience was lulled into thinking this was just another drug user. He was not just another drug user, and many people who die of opioid overdose are more like him than we think. I wonder how many times we turn loving parents into drugged-out zombies or faithful spouses into shades. There was more than meets the eye in this man, and, because we couldn't see that, we contributed to his death. I may not have written the scripts, but I put him in a box. When we do this as a profession, the consequences can be severe and permanent. Ninety-one people die of opioid overdose each day in the United States. Some of these people had little from the beginning and, no matter what we do, will still die of opioid overdose. Some of these people won't die, but only if we change. We have to change. Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "The Box," by C.K. Migliore.