Monday, February 8, 2010

The First Time

Many of us in medicine are fortunate to treat and guide a patient through "the first time" they have a medical emergency or newly diagnosed illness. Of course, sometimes we are skeptical about that "first time" line, but more often than not my experiences have lead me to believe that the patient is telling the truth. At least in his own mind.

"I've never had a drink before tonight." (Say that with a slur, by the way.)
"Honestly, doctor, I thought the pills were Tylenol. I've never used Vicodin before."
"What? I don't know how that cucumber got up my ass! This is a first for me!
"I can't remember ever having burning like this."

You get the picture. So when a nurse ran up to me with an EKG that showed some serious abnormalities, I quickly followed her to the patient.

Surprise! I walked into a room that contained an anxious but very polished thirty-something female. She was dressed to-the-hilt in designer clothes, her make-up refined and her hair perfectly coiffed and colored. She couldn't be the owner of this EKG!

I looked at the nurse with a questioning face and she nodded her assurance to me.

I turned to the patient and introduced myself. "Maam," I said, "what brought you to our ER tonight?"

" having...a hard time breathing," the patient spoke, clutching her chest, "and my heart feels funny." I could smell the hint of alcohol when she talked, her sophistication taking a few steps back.

"Do you have any palpitations with your difficulty breathing?" I asked. She nodded yes. "Any previous heart or breathing problems?" This time, a no nod. "Any recent cough or cold symptoms?" No. "Any trauma, leg or calf pain?" Another no.

"Doctor," she said, gasping for air between her words, "I have to be honest. I tried cocaine for the first time tonight and this started right after. Does this happen to everyone?"

I should have known. This was a woman who didn't smoke, didn't have any family history of heart disease, and had no past medical history of hypertension, high cholesterol, or diabetes. No serious cardiac risk factors. In other words, healthy. Except, and this is a HUGE except, she chose to use crack cocaine. Disappointing, for sure. I could only hope that she was being honest with me, because if she was a regular user and not a first-timer, her heart could have already had significant damage before presenting tonight.

"Am I going to be alright, Doctor?"

"Maam," I said, pulling out her EKG to review it with her. "I think you should know that your EKG is showing some serious findings. It looks like your heart is straining to the point where you are having a heart attack."

"Me? A heart attack? No!" She looked at me incredulously. "Are you being serious? I'm only thirty-two." I nodded my head up and down. "Yes, I am being serious, unfortunately." There was no sugar-coating this.

The patient looked at her friend sitting in the corner who, up until now, had been very inconspicuous. "Laura, you better call Larry and tell him to get here right away. And don't tell him a thing. Just tell him I'll explain everything when he gets here." Laura stood up and wiped her nose with a tissue before giving the patient a hug. She walked out of the room with her cell-phone. I hoped we wouldn't be seeing her for treatment in a bit, too.

"Is Larry your husband?" I asked when we were alone. "Yes, he is," the patient said, "and I don't want him to know I used cocaine, okay?" I assured her that wouldn't be a problem. Well, not my problem, anyway. She could tell him as much or as little as she chose. I just had a gut feeling, though, that by this end of this day, Larry would be pissed at his wife.

"But I still don't know how this could have happened," she said. I explained to her how cocaine causes vasoconstriction, or simply spasming and tightening down, of the arteries that supply oxygenated blood to the heart muscle. If the heart muscle does not get enough oxygenated blood, then, damage can occur. If the patient is a first-time user, as this woman claimed, it's not unusual to get symptoms within three hours of use. If a patient has abused cocaine indefinitely, silent heart damage may have already occurred. In which case, she could be in very serious danger.

I explained to her what was going to happen next. "We are going to give you some aspirin and some valium, but we need to avoid a few other medications that we would normally use to treat chest pain." Cocaine changed those rules. "Also," I continued, "I want you to know that a cardiologist has been called and is going to be here shortly, to take you to the cath lab."

She just shook her head and trembled. "I know," I said, holding her hand, "it's hard to believe that cocaine can do all this."

She started crying as the nurse began pushing medications into her IV. Her vitals, thankfully, remained stable.

"I have three small kids at home," she said, shaking her head. "What was I possibly thinking?"

I could only imagine what her life would be like after we got her through this crisis. If she survived this crisis, that is. Her family would face some serious consequences for her decision-making.

I explained to her that it was very important we know if she had used cocaine in her past or, as she said, this was truly a first time for her.

"Yes," she assured me, "it was my first time. I mean, look at me. Do I look like someone who used cocaine before?"

I bit my tongue on her question. In reality, yes. She did look like someone who may have used cocaine before. Cocaine has no "look," really. Well, not clothes-wise or status-wise. But it does have a look of desperation when things go wrong, and this patient sure had that "look" now.

We got this patient to the cath lab. Luckily, she had no significant blockages and, more importantly, the medications we had given her in the ER had begun reversing the vasoconstriction before permanent damage occurred. She was going to be alright.

After his wife's successful catheterization, Larry, her husband, came down to the ER carrying a large cookie tray to thank our staff. Yes, he matched his wife's look--a pressed shirt and tie, penny-loafers, and wavy undisturbed hair. With a hint of alcohol on his breath. "I just don't understand how this could happen, though. She's too young and healthy to have had a heart attack."

I just nodded at his words, the silence floating between us like a concrete barrier. I was bound by patient confidentiality from sharing with Larry the truth of his wife's situation and, besides, it wasn't my place to tell him of her cocaine use. Instead, I diverted him and asked about the weather outside.

We shook hands and I told him to share our best wishes with his wife during her recovery. As he walked away from me, I couldn't help but think of their marriage and their three kids. Silently, I prayed that things would turn out okay for this young family.

Another "first" patient, she turned out to be. I thought back to her words. "Doctor, I have to be honest. I tried cocaine for the first time tonight and this started right after." Was it really her first time using? I hoped so, but I've been fooled before.

I can only hope, though, for her sake that this "first" will be her last.

As always, I thank you for reading. The next post will be Wednesday, February 10th. Until then, I hope you have a good start to the week. If you didn't vote yet, please do! This is the final week. I appreciate your support.

Vote for StorytellERdoc in both categories!


Chrysalis Angel said...

Great post. She was very lucky.

WrightStuff said...

Makes a very good anti-drugs advert. I doubt she'll be telling many people about her experience but at least you are.

coulrophobic agnostic said...

The classic "can't happen to me" syndrome. At least she had the sense to wonder what the hell she'd been thinking.

Sometimes I think I was the only person listening to those anti-drug speeches in junior high health class. It just takes the one time to mess you up or kill you. FFS, I understood that at ten years old.

I hope she never felt the need to try anything else for the first time after that.

terri c said...

Scary stuff! I'm hoping right along with you.

Maha said...

Here's hoping that she never touches the stuff again and whatever issues that led her to use cocaine in the first place get resolved quickly for the kids' sake.

Heather said...

Funny...our son is adopted. He was born with enough cocaine in him to kill a small country--his mother stating: "I've never touched'd that get in there!"


:) Voting away!

coulrophobic agnostic said...

Heather, seriously?! That's insane.

rlbates said...

Very nicely written. I'm with you, sure hope things turn out well for the family.

Anonymous said...

I doubt it was her "first" time using. Once a crack-cocaine addict, always a crack-cocaine addict. After her recovery she'll want more.

I have been wondering lately what will cause me to need medical attention. It's kind of like thinking about how you will die etc. After a recent positive health check-up with my GP, I sort of feel like a medical emergency is not in the near future, and so how would I ever need medical attention in the next 20-40 years, besides giving birth if I am lucky? Humans are pretty resilient and on-average, life is pretty safe. It is the choices that we make in the day-to-day that determine where we will end up at night I guess.

The risk of getting run over by cars or trucks or busses in Toronto lately is quite scary, and I also hear that falls are the cause for many emergency visits. Bystander gun violence has gone down in Toronto, but there is a 1:1000 chance. Botulism and food poisoning is always on my radar, but it is hard to feel in-control of this one.

My last visit to the ER was two years ago. I stuck it out overnight because I didn't want to go to the ER at 8pm. I filled up a stainless steel water bottle after an evening class to take home on the streetcar during the hot month of July. As I approached the elevator with my sandals on, I dropped the heavy and full water bottle on my great left toe, and it split the nailbed, cracking the nail. The next day I had to have 3/4 of my nail removed and seven stitches. That evening I planned to go to med school #1 for an information session, and someone stepped on my bandaged toe (OUUCHHH!). The Dr. was so kind to give me the suture kit with scissors in-case I needed it (um, sure). The following week when I had to get my stitches taken out, the nurse left two in, and it still hurt like something was pulling when I got home, and I had a closer look, only to find that the scissors would come in-handy as I had to remove the remaining two sutures myself. Thankfully there was no infection and I treated it with the good old American Polysporin. The lady next to me in the waiting room was in for her second corneal tear, which I hear is probably the worst pain ever, so I felt a little bit better. Bandages were so expensive- I paid about $80 for two weeks of bandages. No one tells you this before getting an injury~!

Katie said...

An excellent reminder about the weight of one decision and the potentially serious repercussions.
<>< Katie

Anonymous said...

beta blockers are contraindicated in patients on cocaine! I just feel special to share my pharmacy knowledge...with someone who already knows it lol.

I have to ask, how hard is it to not pass judgement? I feel like the toughest part of a job like yours would be to bite my tongue and not tell someone how stupid and selfish they are.

SeaSpray said...

You don't miss what you never had.

If you don't cross that "first time" line there won't be a second.

I'm glad she was alright and hopefully ... the realization she might not be around for her children and husband scared her silly... permanently.

Max Coutinho said...

Hey Storyteller,

First of all: thank you so much for having dropped by blog and left such an excellent comment there :D! I hope to see more of you there: you are very welcome at MAX.

Now, your post: fantastic writing! Superb account of events!
I admit that I wondered if this experience had ever been her first cocaine trip as well. People fool others, so we never know. But what concerned me was the alcohol breath on her husband's being; I mean: what about the children? What kind of life are they leading? *nodding*...those were my worries, cause what adults choose to do, it is up to them; but when children are involved, then it is a whole different matter.

Excellent post, and I will be back for more!


Anna said...

Excellent story again. You know may be she was telling the truth, and lets hope that was her first and the last. May be someone is looking after her and her children, to give scare her a bit. Thanks for sharing your story. Anna :)

Tonjia said...

great story, I have seen this before countless times. I believe that it was her first encounter with Cocaine. The cath would tell the tale.

People dont realize just what how damaging their
recreational drugs can be... Cocaine is a rich persons drug, and it doesnt discriminate.
I Had a 20 yr old college football player have a Cocaine MI once, we lost him.... how do you tell the parents that your straight A college athlete just lost his life due to something that he chose to put into his body? I am glad I wasnt the bearer of that news.

Peter said...

Sounds all too familiar. A friend, fit as a fiddle one would have thought, complained of chest pain.

No matter how much prompting to get him to go to hospital, he continued to work. He put it down to something he ate - that sounds all too familiar as well.

Later I found out he had suffered a heart attack. He's on top of the world now that he's had a few stents put in.

Funny thing is, he was passed fit after a echo stress test just weeks before.

Just can't tell when the poo's going to hit the fan, can we?

Take Care,