POKER

POKER

On the left side of his neck was the tag tattoo “King “emblazoned over the image of the playing card known as the ‘suicide king’. A fitting symbol for the arc of his life.  For King was here this morning at a “beginners’” meeting announcing in the hushest of whispers that he had six days back since his last drink. What had happened? The last that I heard, he had gotten sober in 2007.  But King chose to remain silent about his “slip”.

As his moniker suggested, King had led a group, in his case a drug gang in Castleford. It was small, so I had been led to believe, but big enough for him to have lived up to the image that his name implied.

He had regaled me with stories of how rough and tough he was; how he could smoke crack cocaine all day and night – in fact had to.  How he never knew that marijuana was even a drug. His street culture was so insular that the only thing he knew about marijuana was that it made him feel good – like drinking.

Maybe the fact that it was illegal was an inconvenient truth which he chose to ignore since the crack and heroin were so much “badder”, drugs that had penalties far outstripping the mere misdemeanors he could get for the maryjane.  It was all part the game, his gamble in life.

But after years of being a junky and becoming a junk user, and having ‘socials’ (as he called them) into the night, life caught up to him. He already had plowed through two marriages and was doping and drinking through his third when he found himself down and out in Washington state, in the snow, in the Cascades, with his third wife who was not only a heroin addict but very sick with AIDS. The last deck was being dealt.

He was head over heels in love with her, but they found themselves broke, in a cabin, cold and stuck for days in the snow, in the mountains. It was supposed to be fun but she started in with a fever and then a racking cough. Then she couldn’t take any food and she did not even have the energy to shoot up. One day he could not arouse her.

And King, not being at the top of the hill anymore, was at the end of his game, and of little use to his wife and that night she died in his arms, after a few final listless coughs.

He called the cops to try to save her not understanding it was too late; that’s how scattered his thinking was, and she was pronounced dead at the emergency room. And while the police questioned him, their inquiries back East yielded an outstanding warrant on him for the selling of illegal drugs and he wound up serving four out of seven years for the possession and sale of narcotics.

But King got a lucky hand, for in prison he found AA and God and upon his release he started to come to meetings, picked up a hardnosed sponsor, and eventually became one himself.

But King remained troubled. He used to share how he would look in liquor store windows and stare at the liquor bottles fantasizing how this single malt or that premium vodka would taste – always trying to remind himself simultaneously that it was all the same to the alcoholic in him who never before drank any of these drinks for taste but only for effect.  All else was effetism, a false strutting peacock parade just to confound the real compulsion to drink.

So for years he would come to meetings and serve as an inspiration to those who had to overcome all kinds of obstacles. For him, one of those was the insidious progression of Parkinsonism, which came on in his fifties no doubt from the ubiquitous  and probably tainted marijuana that he used to smoke.

For years while he was maintaining his sobriety, he tried to get his sister to join him and give up her heroin addiction, with small success.  But finally, when she could no longer walk because of a chronic back injury, she could no longer trawl her neighborhood for her drugs and had to a last detoxify from the stuff. And that was thirteen months ago; so what happened?

I might only speculate but, will not attempt it except to say that during that time I can count about twenty times that I saw him at my meetings after I stopped  picking him up and he had to either rely on someone else or take public transportation to our meetings.  Although he lives within blocks of many churches with meetings, he no doubt was “moving toward a drink”.

What pushed him past his edge? I’m not going to take his inventory because it is tough enough for me to recognize and acknowledge where all of my own faults lie.  Except to say that as most of our stories about what it takes to get into the program can be recognized by anyone in the program, the tools for staying sober, with minor variation, are pretty much the same.

If the program were a deck of cards and sobriety a winning hand at poker, the tools that might work for me or someone else, say three of a kind, two aces or high cards, might not work so well for King. He might prefer four aces, or all picture cards, or straights.

The constant is that we use the same deck! But I would submit for now when all is said and done, a pair of deuces here just beat out one King.

© res 8/22/11

ON EMPATHY

ON EMPATHY

It’s important to get all of my prejudices out on the table. And being an admitted alcoholic bears no relationship to my own sense of hopelessness, depletion, exhaustion and yes, disgust when I have been required to take care of alcoholics during my stints as a resident many years ago. And then when I was out in private practice, this was replaced by an overwhelming sense of helplessness when alcoholics would ask if I could help them to get sober. I never learned how to do that. My initial training was only geared to “tuning ‘em up and getting ‘em out”.

Francisco was  twenty four when I first saw him in the emergency room more than thirty years ago. Through repeated admissions for the same diagnosis, decompensated liver disease, I got to know him pretty well.

He was a handsome guy, with a fine physique, well muscled and a winning smile when he wasn’t all tanked up and bloated with fluid retention from his diseased  liver. Twenty four and he had liver disease that caused him to accumulated fluid in the abdomen which we call ascites.

Ascites is the serum part of the blood  that gets exuded into the abdominal space as a result of the normal osmotic shifts of fluid. And each time Francisco (Poncho, for short) was admitted, his abdomen would have achieved such distended proportions that the fluid would push up against his diaphragm decreasing his ability to breathe. So he would be admitted for shortness of breath and acute liver failure until we could stabilize and then discharge him.

It became almost a ritual that for the first few hours of Poncho’s admission to drain a few liters of fluid out of his abdomen just to make him more comfortable, make it easier for him to breathe and to decrease the chance of him coming down with a hospital acquired pneumonia. And in the meantime we placed him on fluid restriction to reduce his fluid retention, give him good food, vitamins and especially vitamin K to prevent him from  vitamin K deficient bleeding disorders that attended his liver disease. And I dwell on this aspect of Poncho’s care because that is the kind of care that I could give him.

Each time he came in. Every 2 to 3 months.

And with each admission, the level of emotional involvement of the nursing staff of the emergency room (and me, to be sure)would drop. His admissions and reports would become “routine”- his admitting history and physical would be “routine”, and the empathy quotient for him dropped until he became a cipher, a boring copy of himself, an annoyance even. For Poncho never got better.

Because we could never treat his real problem, just his acute problems, which sooner or later we would be unable to treat at all. His trajectory would ultimately lead to acute pancreatitis and death, or acute heart failure and death, or cirrhosis and death, or portal hypertension and finally death. And that death would come sooner rather than later.

What of AA or a Twelve Step Program? Well what of it? Thirty years ago I was only vaguely  aware of it except to know that AA was for drunks; and I was as ill informed about AA as anyone else; for I believed that this meant that AA had active drunks in it. So why would I send a hopeless alcoholic patient to AA?

I’m sure that part of my ignorance was self willed because even at that early time, when my drinking was quite under control, I still had my concerns that perhaps I liked my wine a bit more than the rest of my peers.

My point is that as Poncho became a regular, our familiarity with him wore thin. We got tired of him, less tolerant of him and his treatments became like a revolving door. And although his care was not at the expense of anyone else, the services spent on his behalf were legion.

During my time there alone he probably racked up more than two hundred thousand dollars in hospital expenses in 4-6 admissions (in 1978 dollars).But Poncho’s wasn’t the most devastating case of alcohol abuse that I took care of.

Sam was a forty-five year old accountant who was as affable as they come. A family man, he had success written all over him – Until one day when he started to vomit up coffee ground blood. And then he had runny black stools. And before you knew it, Sam was vomiting up lots of red blood and he was rushed to our hospital and admitted to ICU where he was endoscoped and found to bleeding esophageal varices.

Varices are like varicose veins of the esophagus which result from the buildup of pressure in portal venous system which drains the liver. The chronic ingestion of alcohol causes scarring of the normal tissue of the liver as it tries to metabolically detoxify the alcohol that is ingested. The scarring causes the blood to back up from the liver to the esophagus causing the swelling of the veins around the esophagus. Any minor trauma or sudden rise in blood pressure can cause fatal GI hemorrhage.

Even nowadays, with improved treatment, it often takes heroic efforts to stop such catastrophic bleeding and save the patient. In the 1970’s these methods were just being developed.

Not in time for Sam, however, and he died from circulatory collapse from the acute blood loss.

I felt badly about Sam. Was that because he was white and middle class and not a young Hispanic  or was it just that in him I imagined that I saw a reflection of myself; and if this disease could take out Sam, then perhaps I should  have some guarded concern for me?

But true alcoholic that I was, I waved away danger with the flick of hand.

Time has passed and of course I am one of the lucky ones, here with my diagnosis, alive and intact and my health still preserved. No major crises or hospitalizations… yet. But I still wonder about that notion of mine and my colleagues’ ebbing empathies about treating chronic relapsers. I always had the notion that seeing so many drug addicts and alcoholics just depleted all the stores of feeling that I had for their suffering. They just seemed not to want to get better.

At  a meeting in the rehab center I brought up this inconvenient and uncomfortable truth to the group who seemed to think that they could continue to be brought to busy emergency rooms, either strung out or actually OD’d on some drug or alcohol and command the attention and sympathy of the medical staffs. I tried to warn them that even the most empathetic of medical caregivers can shrug at the hopelessness of the situation and finally become inured to the pain that is out there. It is a protective mechanism for them.

 And as they do not know that I am a physician, my news may not have carried as much impact as it might have, had I revealed my profession. But I said that if they did not wise up to the fact that repeated visits to the ER can result in the battle fatigue of these staffs, then they had no right to expect the unwavering compassion from people who do not understand the way they think, the way they act and what they are doing to their minds and bodies.

I was roundly criticized for this and deemed to be “non empathetic”. And perhaps this might not have been the wisest news to present to patients in the first few days of their detoxification or recovery from substance abuse or from being brought back from a suicide attempt or accidental overdose.  This is, after all, a sensitive time for them.

But reality is reality. And within days, they are going to be thrust out into that real world; that uncaring, uncompromising, cold and critical and un-empathetic world.

Perhaps they should understand that they might pull the overdose stunt just once too often to pray upon the sympathies of those in whom they entrust with their care.  And who could blame someone for thinking that sneaky, insidious, almost frigid thought of “why should I care for someone who has so little regard for himself? ”

© res 8/8/2011

AMAZING GRACE

AMAZING GRACE

I approached the detoxification unit with trepidation, as I did each Wednesday, always wondering the same thing. What did I think I had to offer these early recovering alcoholics and drug addicts that they might not have gotten from the institutional sources that they were already attending? What was indeed the point of it all?

Of course, that was not the point at all. What I had to offer was irrelevant. All I served was as a conduit for ideas that flowed in and around the rooms of AA, notions that I channeled with the aid of one of the approved AA literature books called “Living Sober” which I used as a guide for this meeting. 

But I must confess that each week that I enter the ward, I feel I am in a place where ‘raw’ is an adjective that just scratches the surface as a description for the pain that seethes below the emotional surface of the patients here. And when you sit at the ‘head’ of the circle of the group, paradoxically placid faces stare at you which you feel at any moment will metamorphose into the most bizarre masks of emotion the moment you turn away.

And then you begin to read some chapters in the book so that when they finally leave this cocoon, they will have some tools with which to deal with the world they are facing when they step to the other side of the locked doors. And we read “Looking out for over elation” a chapter that seems preposterous on the face of it when looking into these masks of distant reserve.

Yet somehow this strikes a chord; yes, they recognize the incongruity.  One says that he would drink when he was happy, and another, when he was blue. Still another drank when he was angry and another when she was ecstatic. I said I drank when I had a particularly satisfying day at work… or not!

Obviously, we drank over anything or nothing at all. But we drank and it took only just a bit of being “off the beam” over or under the beam, to be off it.  In fact I said that a friend of mine liked to say (sardonically) that “I only drank when he was alone or with somebody”. It is all an excuse, so beware of the circumstances that change feelings for they make us want to drink. Hunger, anger, fatigue, or loneliness, those are the culprits.

And then this was followed by “Easy Does It”, clearly a nice sequel to the previous chapter to remind us not to get upset by situations that could get us “off the beam” either too hi or too low. We should avoid extremes of emotional engagement in most situations and certainly for the first year that we are trying to get sober. It is during this period, when we are most vulnerable to irrational thinking, thinking which is more magical than real, more fanciful than solid, more fancied than well thought out.

“Being Grateful” followed and in it we are reminded to take one day at a time, live in the day and not to worry about tomorrow and project about all of the horrible things that could befall us, or to stew about all that has happened to us in the past. Being grateful for the present’s goodness and serenity should keep you in the moment dealing with the here and now so that the future can take care of itself when it arrives.

And then the big, one “Remembering your Last Drunk”. That got the room talking.  J recalled that his last big drunk was not his last drunk ever but the most memorable one and one that scared him into his current detox/rehab. He was found head down on the marble floor of Penn Station sent to the ICU of NYU with a frontal lobe traumatic brain injury from a contusion to the head. With a .45% blood alcohol level – when found he was nearly dead.

After multiple reversible organ failure, the toxic alcoholic insult to the brainstem  left him unable to walk without an unstable gait, but he was finally discharged to a neuropsychiatric  rehabilitation center and then home for a six month recovery period. 

“And whatever I was thinking when that drunk happened, when I next went out, I never wanted to go back there again; but I tell, you, I’m scared to death that I might yet go there and that’s why I am back here.” 

For J hadn’t just lost much of his physical well being during that last drunk. He lost his job, his car, his house is now in foreclosure as is his marriage.

He figures that he can recoup everything if he reminds himself to stay sober one day at a time-not to get his job back, not to get his car or his house or even his marriage back. But to get his sobriety back.

Because if he strays from attending to his sobriety in the mistaken belief that attending to his marriage, job, finances or family  should somehow  be a priority, he realizes that he will have neither sobriety, family nor the rest.

Which led M to speak about his current reason for being here for this detoxification, as he sighed a weary and breathy sigh of resignation. “I had been taking care of my girlfriend’s sobriety first and not paying attention to my own.  I made sure that she went to her meetings, she had her job taken  care of, she got to the bus station on time, and all of my needs were secondary.

“My support system was to support her and when she went out that left me without a support system. And boy did I lose it all, a car, a bank account, an apartment, everything! Do you know what it meant to me to have a bank account?”

And in truth I could not understand what such a simple and commonplace convenience such as a bank account could mean to this guy but he was clearly upset by the loss of the account. He was more upset by the loss of the account than the money in it! The account meant stability, validation, being someone. It meant that he was reliable and an upright member of the community; and now he had blown that all away for some crack cocaine.

“I can never go back to that woman. I have to get myself sober and take care of myself before anyone else. I am too old to be doing this over and over again. I want to be  normal  again; but I can’t until I am sober. And I can’t get sober unless I put my sobriety above everything else in my life; other people, other things, jobs, family and friends. It has to be me first!”

And then M turned to me and asked me for a copy of the Living Sober book. He needed all of the tools to get it right this time.

Then GC piped up to say how she thought she had understood clearly how to maintain her sobriety. That whenever a drugging situation would present itself, (she used cocaine), she would stop to think about her motivations as to why she wanted to use or why she was even considering using. “That works best for me – if I understand what I am doing. Self knowledge, that really works!”

 And I indicated that it was well and good to be analytical in trying to understand motivations and changing behaviors. But when you need a solution at the moment that the problem hits, analysis is not going to do you much good.  You must be prepared to act in a different mode of behavior first and analyze the situation later.

The time it takes between the presentation for a drink, (such as a hearty greeting of long missed friend), and the opportunity and time to examine the motivations and reasons for not engaging in that behavior, especially for the alcoholic or drug addict in early recovery, may be seconds. And without pre thought out strategies, you may be lulled into the false notion that “oh just one can’t hurt”. Even though you know that it's the first drink that counts,  after that, all bets are off.

As for myself, I can say unequivocally, I never had just one drink. And I can say that in any room of alcoholics they will confirm that too. Which is why we have to do whatever it takes to stay away from that first drink one day at a time.

I find it difficult not to preach to the “young people” in the program. And by “young” I mean those who have tried and failed and then tried and failed  again and again to get sober “their” way.  And "their" way consists of first not admitting that they have a problem at all. We all do that.

Then we think that we can get sober by ourselves and, then we think, by some form  of “self knowledge” discovery,  as if knowing that we are alcoholic will change our behavior,  we go on to believe that we can lick it – by ourselves.

 We have behaved alcoholically for so long that it is automatic and those automatic responses must be interrupted with some strategies to short circuit that conduct with new alternatives for dealing with situations that would ordinarily cause us to partake of a drink.

So to the "young people", the uninitiated, or those who have not yet been willing to adopt the program, I urge that they try to put some new AA arrows in their quiver. Even while on the path to “self exploration” just so that they will have quick and ready options to follow when “their best thinking” leads them to choose  a course that got them into this situation in the first place.

So the purpose of using a book like “Living Sober” is to be able to gain that automaticity of behavior long enough to get past the most dangerous period of early sobriety. It gives us the breathing space to get to that place where we can  discover just what it is about ourselves that makes us drink; to have that clarity of thought to fend off those temptations in early recovery and have the unfettered time and attention to stare at our navels to learn just who we are and how to go about mending our broken selves.

© res 8/8/2011