Bonnie Milas knows exactly how quickly a dose of fentanyl can stop the breath.
A cardiac anesthesiologist for decades at the Hospital of the University of Pennsylvania, she works every day with the drug that, in its illicit form, has contaminated most of Philadelphia’s heroin supply, and is now blamed for killing thousands.
Many more are saved by quick administration of Narcan, the same reversal drug that Milas uses in her operating room for patients who don’t wake up quickly enough from anesthesia.
Her medical training is the reason she knew what to do the day she first found her son Robert overdosing in her home, and how she saved his life with an intravenous dose of Narcan she happened to have in her medical bag.
It is also how she knew that nothing could be done on the January morning last year when she drove frantically to an apartment in Philadelphia, pushed past a police officer, and saw her son on the bathroom floor. Robert was 27 and, even that early in 2018, already was the city’s 16th overdose victim of the year.
A toxicology report would find only fentanyl in his system.
Last month, her family suffered yet another devastating loss: Her older son, who had saved his younger brother from overdoses twice and was Milas’ only surviving child, himself died of an accidental drug overdose. That loss is still so fresh she cannot fully discuss it.
In the wake of unimaginable tragedy, Milas has committed herself to educating others on how to prevent overdoses. She has spoken up at university forums on the opioid crisis, advocating for supervised-injection sites as a lifesaving measure in the crisis gripping the region, where medical personnel monitor users, reverse overdoses, and also help connect them with treatment.
From her home in Yardley, she’s joined the Bucks County Overdose Prevention and Education initiative, hosting Narcan trainings and encouraging parents to develop the kind of overdose-prevention plan she didn’t have when she caught Robert, then in high school, hiding a syringe.
Robert had been an intensely curious child, a brilliant math and physics student who struggled with other subjects and had been diagnosed with attention-deficit hyperactivity disorder. It was like him, Milas thought at the time, to have tried heroin just for the experience, and she believed him when he assured her he never would again.
She would think later that it made a kind of horrible sense that Robert would choose a downer as his drug of choice: something to calm his mind. “For him to feel better about what it is that he was feeling,” she said — intense self-doubt, sensitivity, and inadequacy.
“They were expectations he was setting for himself,” Milas said. “We didn’t care what he chose to do, as long as he put his heart and soul into it."
At first, she found it almost unbelievable that her kind, funny son, who made her laugh harder than anyone else, could fall into addiction.
But her physician’s training meant she eventually began to see signs she couldn’t ignore. Robert’s constricted pupils. How he would fall asleep upright. How he would become suddenly exuberant, bubbly, eager to please, after a dose of heroin pulled him out of withdrawal’s painful symptoms. Even his speech was a tell: On the phone from college, Milas would listen to the timbre of his voice, the ragged edge of his breath, and know he had been using.
She never shared what was happening with anyone outside the immediate family, even as Robert slipped into full-blown addiction, struggling in and out of rehabs, overdosing again and again. Milas, her husband, and her 90-year-old father-in-law each saved Robert from an overdose.
Milas and her husband feared the stigma their son would face had his condition been more widely known. “We were never ashamed of Robert,” she said. But the couple sat through dinner parties where acquaintances blithely talked about how any parent whose child succumbed to addiction clearly had not spent enough time with their kids.
“This was 2009, 2010. There was no opioid crisis. There was no information out there whatsoever,” Milas said. The family endured in silence.
But since Robert’s death, Milas has felt compelled to speak up. She wants to help the families of people in addiction to prepare to save their loved ones’ lives, to have a plan to deal with overdoses. Dinner party guests might think suburban kids are safer. But Milas knows ambulances can take longer to arrive in the suburbs, and so it’s even more critical that families know what to do.
“We’re extremely grateful to her,” said Diane W. Rosati, the executive director of the Bucks County Drug and Alcohol Commission, where Milas developed her Narcan training program, working with a local paramedic. “As a representative of government, we can’t have every base covered — community members have a willingness to step in and help, and this is a tremendous example of that.”
Milas encourages families not only to carry Narcan — in a nasal spray formulation — but also to learn rescue breathing, chest compressions, and CPR to help loved ones breathe until paramedics arrive. Opioids kill by suppressing respiration, she explains.
Above all, Milas is making it OK for worried families to talk about what to do if the thing they fear most happens.
“It’s a terrifying situation for family members, standing there, not knowing what to do,” she said. “I’m trying to get loved ones, neighbors, whoever, to take another step forward.”
Every day, in the operating room, Milas administers the drug that killed her youngest son. In her hands, it is a lifesaver that makes surgery safe and eases the worst pain of illness and injury.
Milas keeps a CPR dummy in her office and demonstrates rescue breathing techniques with clinical precision, even in the grip of an unspeakable grief now visited on her twice. She keeps doses of Narcan spray on hand, too — because, she says, you never know when you might need it.
A short time after Robert’s death, Milas was driving in Bucks County and saw a police officer performing CPR on a young man lying on the ground next to his car. There were no paramedics on the scene yet, and she stopped to ask if the officers needed help.
On the side of the road, she ended up reversing an overdose. It wasn’t just because of Robert that she felt compelled to pull over: She is a physician. Her job is to rescue people. But her son is why she will always carry Narcan, and why she hopes everyone will.
“Get trained. Get the skill set. You won’t have any regret," she said. "And you won’t feel that, I should have done something, and I didn’t.”