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?"

"I...am 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.

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