Author:  Amelia Smyth

Editor:  Abhi Pal

 

We are 10 minutes into our late meal break and the radio announces a code one job two blocks away. The pager message reads OVERDOSE: INEFFECTIVE BREATHING. My partner and I swap looks of discontent and roll our eyes. Another meal-less shift, for another junkie. We travel to the job lights-and-sirens, and enter the house via the front door – which is wide open. From the doorway I can see a woman, amongst rubbish and general household debris, sobbing as she performs ineffective CPR on our adult male patient. We enter the room and I can see that the man has visible lividity and early signs of rigor. I attach our cardiac monitor, whilst my partner pries the woman away. I listen for heart sounds and hear none, as the familiar flat line of asystole traipses its way across the screen in front of me. His skin is cool, and dry. I radio for police attendance – as is standard in all pre-hospital deaths not due to known illness. We explain to the woman that her partner has died, likely earlier that morning. I offer her reassurance. She appears confused; asks what time it is. She believes it is night-time. Explains they had been on a binge, for an unknown time period, an unquantifiable amount of drugs, mostly heroin. She becomes distressed, asks repeatedly why we aren’t giving him ‘Narcan’ like last time, why we aren’t doing CPR. I explain again, he has died. Again, likely hours ago. I become frustrated, conscious of not touching anything around me. Most of the surfaces are sticky, and there is a smell I can’t quite identify. The police arrive and we handover.

When I re-read this I cringe. I feel the need to explain, to reassure readers that I did care. That I was a warm and compassionate health care provider. I held hands, and wiped away tears. I want to excuse my behaviour as contextual. It was because of the frequency of these calls. It was because of the times that our patients had young children watching on as we resuscitated them. It was because of the amount of times I finished my day angry, tired, confused, underfed and under-appreciated. Because of the times we were hours late attending the 89 year old who had fallen in the bathroom, due to having to resuscitate the same 20 year old overdose twice in one day. But from where I stand now in my professional life, I feel there is no excuse for the thoughts I harboured about this woman’s situation. I allowed my ignorance to cloud my compassion, and stigma to influence my ability to empathise.

I am now an emergency nurse. My occupation change brings a slight variation in scenery, shift structure and responsibilities. The people I see, and their health concerns remain very much the same. Some of the patients that present to our ED happen to have substance use disorders. It may be the primary reason for their presentation, or merely contextual to their injury or illness. The frustration, judgment and limited empathy conveyed in my opening paragraph has also changed. I don’t look back and see any particular ‘light bulb moment’, but rather a series of exposures. I have been privy to multiple, varied patient experiences of ‘health-with-a-side-of-substance-abuse’. Most poignantly, I have observed colleagues – of all disciplines – enact behaviours and assumptions similar to my  own in my opening paragraph.

A certain catalyst was the exposure I had whilst employed within an acute detoxification unit as part of my first year of nursing. In the short time I spent within the twelve-bed, public-hospital ward, I became immersed in a world I previously had very little knowledge about. Patients almost always came to us acutely intoxicated, due to pre-admission binge like activity. This made for fascinating real-time observation of withdrawal symptoms. I very rapidly learnt which substances had potential for medically dangerous detox, and which were merely symptomatically managed – though still uncomfortable for those undergoing the experience. Through conversation alone I learned more about human condition than I have by any other means to date. I was brought to tears on numerous occasions reading patient notes, and was challenged daily to maintain my preexisting assumptions about what kind of circumstances created the addicted person.

One particular evening shift our unit was full, and uncharacteristically moody. We had a real diversity of individuals, with varied personal and substance use history. There was no one way to categorise each of the twelve patients we had in the unit. Each person was male, female or neither. They were detoxing from alcohol, opioids, amphetamines, methamphetamines, benzodiazepines, cannabis, synthetic cannabis or a mixture of all of the above. Everyone was abstaining from nicotine and caffeine. Some were illiterate, others had tertiary level education. Most were employed, many had loved ones keenly awaiting their return home. One man had no one but his dog, housed in a kennel for the duration of his stay. I could persist in trying to explain the diversity of this one particular evening, but I would be diluting the point of my story.

He was a young, charismatic, twenty-something who enjoyed intelligent conversation and clever banter. He was from a family of polysubstance users, and had only in the last 18 months lost his father to complications of drug and alcohol abuse. He was admitted to our ward within the rehabilitation-instead-of-remand program; completing those seven days with us was his last chance to avoid long term gaol.

This particular night he claimed to be bored. Just bored. My observations suggested he was beginning to experience the anxiety commonly associated with the first few days of methamphetamine abstinence [1,2]. Years of poor role-modelling behaviour, and insufficient social support structure meant he lacked the emotional maturity to deescalate his own rising discomfort. We chatted in private, and he explained his rising anxiety. Felt he wanted to remain within the unit, but was also battling with conflicting feelings of feeling trapped into a situation he hadn’t himself chosen. He felt his whole life he was forced to choose between two bad options. He was tired of trying to figure out the lesser of two evils. After some time of reassurance, and increased rapport he appeared more settled and returned to the tea room for his evening meal. I felt relieved for the moment, though simultaneously heartbroken at the obvious turmoil of this young man’s life. I also alerted our senior nurse to the situation, and my concerns.

Shortly after dinner he began swearing loudly and acting out. He kicked furniture, and began pacing the unit. His behaviour was now not only disruptive, but potentially dangerous. We had eleven other adults within the unit, simultaneously undergoing varying stages of substance withdrawal – each of them were anxious, on edge and battling their own troubled histories and conflicting desires.

The unit was run under voluntary admission basis; patients were medically and mentally deemed as having decision making capacity and thus were free to discharge at any time they wished. They were also contracted to a list of behavioural expectations for the duration of their stay, in the interest of maintaining an environment of safety for all enclosed. As per policy, he was issued a verbal warning about his behaviour. The threats escalated, and I eventually retreated altogether. My colleagues, as well as other patients were now acutely aware of the drama unfolding. A staff decision was made to offer voluntary discharge to my patient. If denied, he would be requested to leave – whilst acknowledging a duty of care for his immediate safety – in the interest of the greater good of the patients, and the staff. I was personally affronted. I had spent days building rapport, and in that moment maintained a desperate belief that this opportunity was his final chance at restitution.

The young man left the unit, not without incident. Three further patients self-discharged that same evening. I became acutely aware of a greater societal system breakdown for these individuals.

I have no idea of his whereabouts now, and no idea of the trajectory of his life henceforth. I have no idea of any of the wellbeing of any of those wonderful human lives I had interaction with in the few short days they spent in the unit. I know in-depth details about their pasts, their many motivations for substance misuse, the many times life abused them and their trust. I know about the moments they made decisions that brought them to our front door, and I saw the pain they were in whilst intoxicated that first day – and saw that pain grow as they were forced back into the reality of our harsh world. There were histories of repeated physical, mental, sexual and emotional abuse. I could now no longer maintain my previous assumptions about an individual’s ‘lifestyle choices’. Not after such direct exposure to the difficulties faced within even the most dedicated units, with specialised staffing, with willing and motivated individuals.

I look back to my opening paragraph and know with certainty that had I the chance to do-over that scene from so many years ago, I would have simply offered more of my time, and less of my judgment. Made available a more empathetic explanation of what had occurred. I’d have shown more compassion, and warmth. I now see each of the overdose presentations as a devastating reflection of the state of addiction in my country. Of the impact addictive substances have upon people’s lives, and the greater community. I do not waive the responsibility of the individual, nor assume helplessness or lack of agency. I just hope to remove the barrier that stigma creates, and promote an open mindedness in approaching my fellow human – regardless of personal opinion pertaining to another’s life choices.

Obviously, this is an ‘opinion piece’ of writing, but unfortunately my original opinions were not only mine own. Multiple people within our professional and personal lives maintain such opinions [3, 4]. Perhaps though, next time you encounter someone with suspected or confirmed substance use concerns/disorder you can attempt an open, non-judgmental conversation. Then with the information from this conversation, assess whether any form of assistance may be needed. The person in front of you may not accept that assistance in the first instance, nor accept it in the tenth instance. But come the day that there is a perceived greater level of societal compassion, the foundation of trust and respect shall be laid. I believe that on that day positive health-choices shall appear more available, sustainable and easier to make. Our doors shall be appropriately open, and we shall provide a safe landing platform from the merry-go-round that is substance misuse.

 

References

1.  The Department of Health, April 2014. Models of intervention and care for psychostimulant users, 2nd edition – monograph series no.51. Available from: http://www.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-modpsy-toc~drugtreat-pubs-modpsy-3~drugtreat-pubs-modpsy-3-7~drugtreat-pubs-modpsy-3-7-aws)

2.  Australian Medical Association. AMA position statement on Methamphetamine. 2015. Available from: https://ama.com.au/position-statement/methamphetamine-2015

3.  Leonieke, C.B., Brouwers, E.P.M., Weeghel, J. & Garretsen, H.F.L. 2013. Stigma among health professionals toward patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and Alcohol Dependence. (131) pp.23-25.  Available from: doi: 10.1016/j.drugalcdep.2013.02.018.  Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23490450.

4.  Neville, K. & Roan, N. 2014. Challenges in nursing practice: nurses’ perceptions in caring for hospitalised medical-surgical patients with substance abuse/dependance. The Journal of Nursing Administration. 44(6) pp. 339-346.  Available from: doi: 10.1097/NNA.0000000000000079.  

Abstract available from:  https://www.ncbi.nlm.nih.gov/pubmed/24835142.

 

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