Heal Thyself

Rapid detox leaves a nurse suffering unforeseen side effects

Karen Augustine remembers being a nursing student in Pennsylvania, where she was raised, and hearing from her teachers that "one in seven nurses would become chemically impaired" in the course of their careers. She just didn't know at the time that she would be the one. And until the past few months, she didn't really know what she says she knows now, which is that working for a hospital "kind of sucks, because if you get sick it's a big deal." But when Karen Augustine recognized her sickness, and tried to get well, she discovered just how big a deal it can be.

Discount a slight tremor attributable to the aftermath of addiction and the nervousness of appearing in a newsroom, and Augustine looks every bit the nurse. She's a reassuringly sturdy woman with coiffed brown hair and an instantly familiar air, but today, as she would easily admit, she'd pass few people's muster as an ideal of the profession. Twelve years in the trenches of all manner of hospital wings has left her with an unnerving gallows humor, a cigarette habit and an authority-questioning bluntness that's bound to rub egos the wrong way in the ego-bound health-care industry. She's also a member of that human subspecies that uses the word "party" as a verb, as in: "To be really honest, I've partied all my life." By contrast, her immediate party problem -- an addiction to the painkiller Vicodin -- has been an on-again, off-again demon for only the past six years or so.

And yet by all available accounts, Karen Augustine has been, over those same six years, an exemplary nurse. Beverly Beck, in her role as nurse manager at Forest Springs Hospital, where both were then employed, reviewed Karen's performance in a "90-Day Evaluation Summary" in May 1995. Beck noted Augustine's "great personality," "caring attitude," "strong leadership abilities" and described her as someone who's "willing to be flexible and follows through with extra assignments as assigned." Under the heading "Areas Needing Improvement," Beck wrote that Augustine "performs at a level higher than that which is required." Beck must have remained upbeat in her appraisal. After moving to Cypress Creek Hospital as director of nurses, she was responsible for hiring Augustine on that institution's staff.

And it's not as if nobody was aware that Augustine had had run-ins with drug abuse. She had a history, after all, at the very same Cypress Creek, where, in 1994, she was enrolled as a patient, detoxing from painkillers, when a hospital therapist recommended her for a nursing position.

"I was a patient on Friday and I started work on Monday," Augustine remembers.

As with most people and their addictions, there are multiple possible explanations, contributing factors, excuses, what-have-you, for Augustine's drug abuse. While Augustine was working at one hospital in 1992, a window fell out of its frame and onto her head. The ER gave her the painkiller Lortab, which, it turned out, she liked. Then there's the fact, as Augustine claims, that her mother was abusive. And dovetailing into the nursing cliche, Augustine learned to give and give to her patients, but never to herself. "It could be that I was using drugs to mask a lot of that," she says.

But at the same time, as a licensed vocational nurse with 12 years' experience, the last four of them attending mostly psychiatric and chemical-dependency patients, she's aware that there are no black-and-white explanations, or excuses, for addiction. "I know I was a damn hypocrite, and that was partly the reason I was so frantic, because I hated living like that."

What her franticness led her to in early May of this year was yet another in a long line of attempts to kick. Having endured several runs at traditional cold-turkey detox -- withdrawal ordeals filling up to 72 hours with vomiting, nausea, diarrhea, cramping and severe shaking -- only to slip back into her habit, Augustine was primed for something more promising.

She thought she'd found it in an experimental procedure called ultra-rapid opioid detoxification under anesthesia, or URDUA. Popularized on ER episodes but still considered just slightly left of the dial in terms of widespread acceptance (which is to say that most insurance plans won't pay for it), ultra-rapid detox works like this: Patients are placed under general anesthesia and given monster doses of a drug called noxalone that jump-starts withdrawal, speeding patients through the detox process in about four hours. Because patients are anesthetized, they're unconscious and sedated through the roughest waters. When they wake, symptoms of physical opioid addiction are largely out of their system. And while ultra-rapid detox is no quick fix (there remains the significant trick of staying off the drug, for which most practitioners mandate a minimum of five days of outpatient drug-rehabilitation therapy), it's advertised as, for some patients, a superior way to achieve initial detox, which for many addicts is the most daunting blockade to recovery.

Ultra-rapid detox -- the cost of which ranges from $3,000 on up -- is currently offered by a limited number of hospitals around the country, including at Methodist Hospital in a study program under the auspices of Baylor College of Medicine, carried out by a Dr. Richard Silverman, an anesthesiologist at Methodist Hospital and Ben Taub General, as well as a clinical instructor at Baylor.

Karen Augustine, as an addict whose medical insurance didn't cover participation in the study, enlisted Channel 13 crusader Marvin Zindler to intervene on her behalf with Methodist, which agreed to let Augustine pay for the procedure on a monthly plan based on her income at Cypress Creek, and dependent on an understanding that she would return to that work after her detoxification.

In fact, it's here that Augustine may have made her gravest error, at least from an administrative standpoint, on the road to recovery. Her HMO coverage includes an employee assistance program (EAP) called Plan 21, putatively designed to provide assistance -- including counseling and treatment programs -- to employees who approach the EAP with their problems. Augustine declined to avail herself of these services because, she says, her experience led her to believe that word of her addiction would filter back to her supervisors and result in her firing.

"I was terrified. I lost sleep over it. I saw it as, if they found out, I'm finished."

The irony of this particular fear wouldn't become apparent until later.
Augustine underwent ultra-rapid detox, under the direct care of Dr. Silverman, on May 15. She came out of the anesthesia stunned by its effectiveness.

"I remember telling him [Silverman] that I couldn't believe how I felt as opposed to normal detox, and I wished that I could go to work and tell them [about the treatment]. And his exact words, and I'll never forget this, were, 'I wouldn't be apt to do that. I would tell them you met someone who had it done.' "

Silverman backed his advised discretion with a note, dated May 18, on Baylor College of Medicine letterhead, faxed to Augustine's Cypress Creek nurse manager Teisha York (who has since moved to West Oaks Hospital). The letter read: "Please be advised that Ms. Karen Augustine was under my care at the Methodist Hospital last week. She was discharged home on Saturday, May 16, 1998. Due to pulmonary complications secondary to intubation it is my recommendation that she remain off work until Monday, May 25, 1998."

The doctor's excuse was accurate, but incomplete, apparently reflecting his knowledge that Augustine's employers might not lend a wholly sympathetic ear to her attempts to kick her habit. That's all well and good; the excuse, Augustine says, was discussed prior to the procedure.

What confuses her is why, then, on the same date, on the same letterhead, yet another doctor's note was faxed to the same supervisor, this one stating: "Ms. Karen Augustine underwent ultra-rapid drug detoxification under anesthesia by Dr. Richard Silverman on May 15, 1998. She will need one week off work to recover from this treatment and to participate in ongoing support." This second note was signed by an Assistant Professor Peter H. Norman, MD -- a man Augustine says she's never met, had never heard of, and has since spoken to only once, when Norman returned Augustine's call to Silverman, who has since departed to Florida for a teaching sabbatical.

It might have been little more than a paperwork mix-up (and, since Augustine insists she never signed any release forms, a violation of patient confidentiality laws).

It might have been, except it was more than that, because when Augustine arrived at a June 2 "return-to-work meeting" at Cypress Creek, she found herself facing human resources director Adrienne Livingston, director of nurses Brenda Schiavone, program director of CD Services Robert "Dr. Bob" Eller, nurse manager York and copies of the two conflicting statements faxed from Methodist, which, sans prelude, they shoved across the table toward Augustine for explanation.

"They started hacking at me," says Augustine. "They didn't even question it, they just blindly broadsided me. Boom. I didn't know what to say. Adrienne asked for my keys and my badge and I was told that I would be suspended without pay pending an employee assistance program assessment."

By July 1, Augustine had received notification that her insurance had been canceled. On July 15, she called her employee assistance program, only to be told that they had never heard of her case (as of press deadline, Augustine has yet to hear from them). And on July 30 she was contacted by the Texas Peer Assistance Program for Nurses, which informed her that she had been "referred to TPAPN because there is a concern regarding your nursing practice," and had ten days to respond to their letter or the organization would be "obligated to refer your case to the Board of Vocational Nurses Examiners for their action," which could include suspension of Augustine's license. All the while, Augustine had been fending off requests for a meeting with her supervisors at Cypress Creek, who, she says, would not agree to her request to have an attorney present.

Augustine contacted her Peer Assistance Program (an advocacy group out of Austin that tries to help get nurses back on their feet), but even that has added to the confusion. Augustine says TPAPN case manager Cathy Dell informed her she'd been fired from Cypress Creek. Augustine, meanwhile, has received no such notification, and an August 26 meeting with Schiavone and Livingston failed to clear up the employment question, with Augustine's supervisors recommending that she contact her insurance company's employee assistance program for an "assessment" -- even though the EAP has failed for over a month to contact her, and her insurance coverage has been dropped.

Augustine says she thinks her rights have been violated under the Americans with Disabilities Act, and the Equal Employment Opportunity Commission has accepted her claim as valid, meaning that, if she chooses, she could take Cypress Creek to court. And she's filed a complaint against Methodist's Dr. Norman, for unauthorized disclosure of her medical records, with the Texas Board of Medical Examiners.

Back on the front end, Methodist's dueling doctors' notes are clear evidence of at least an administrative screwup. One that, at least for the past three months, has cost Augustine her job, and may yet cost her her license. The 40-year-old married mother of a nine-year-old daughter, Augustine has remained clean since her detox, but continues to struggle with mounting bills for follow-up therapy without an income. She's filed for her disability pay, but has yet to see a cent.

Dr. Norman failed to return e-mail from the Press requesting an interview, and Silverman returned via e-mail his regret that "due to patient confidentiality" he was not at liberty to discuss Augustine's care. Silverman subsequently failed to reply to a request for a general interview on the ultra-rapid detox procedure. Cypress Creek human resources director Livingston refused to comment, saying that "[Karen] can give you information however she chooses to breach her confidentiality. She can do that. I cannot." Over at Methodist, spokesperson Kathryn Tesar bounced responsibility to Baylor, and Baylor spokesperson Clair Bassett said that the institution has no comment.

And a comment, really, is what Karen Augustine wants more than anything. She's not even sure she wants to go back to work as a nurse, under the circumstances.

"It's changed, health care. I've done it for 12 years, and with the advent of HMOs and managed care, the patient recidivism rate is so high. It's real discouraging to me.

"The people I worked with, so-called professionals, weren't able to diagnose me themselves based on any behaviors that I exhibited. I was held up as a standard, as a matter of fact, as an exceptional employee. And then the way they reacted when they found out...."

Augustine may or may not want her job back, but what she does want, and hasn't been able to get, is an explanation for why, in doing the right thing, in seeking help, her confidentiality was violated. And an explanation for why, as an employee with a good record and a disease, she finds herself dismissed from a profession purportedly dedicated to healing.

E-mail Brad Tyer at brad_tyer@houstonpress.com.

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