I just logged onto our computer system at work to see what our patient list is looking like and if there have been any emergency surgeries this weekend. I noticed something peculiar about the bed assignment of one of our young patients. I opened a nurse’s note to discover that just two days after we operated to repair one of the heart valves that had been damaged by this patient’s IV drug use, the patient was discovered using IV drugs while in the bathroom.
Of course, they deny any wrongdoing but the evidence is overwhelming. I have no idea how this young person’s life will turn out after the follow-up visits are done, but I can say the chances are they will end up like so many of our other patients that require open heart surgery because of their drug use — dead.
When I was working as a bedside nurse in the Emergency Department observation area in Portland at a level 1 trauma center, IV drug users made up about one-third of my patients. They were bread and butter for us. Usually, they came in with abscesses at their injection sites or sepsis. This patient group was trying to deal with; initially, they would be cooperative and seem as though they wanted help, but after 24 hours, they would start jonesing for their fix. Sometimes they would ask to be discharged quickly because of a “family emergency,” they would want to go outside for some “fresh air,” or they would just leave when everyone’s back was turned. After a while, you get hip to their tricks.
The most frustrating part of caring for this patient population is their lack of commitment/willingness to get treatment. Their entire lives are ruled by their need to get their next fix, and not even going through open heart surgery is enough of a wake-up call to get them to change. One patient pushed me past my capacity to care when she came into the ED with her second bout of endocarditis. The first time around, she received treatment when she was flown from another state by a religious health care organization to Portland to have one of her valves replaced. When she was discharged from the hospital, she looked around and decided Portland was a pretty awesome place to be homeless and do IV drugs. I could not ask even the most basic of questions without snark, apathy, and contempt dripping from every answer. At one point, she admitted that she was just going to keep using until it killed her, even if Cardiothoracic (CT) surgery decided to do surgery to try and save her. She was admitted to a medicine service for medical treatment of her infection while CT surgery decided what to do; I never found out what happened to her.
When I left the bedside, the Emergency Department, and Portland for the long hours of CT surgery in Ohio, I thought most of my dealings with drug users were over. I was wrong. So, so, so very wrong. Ohio is at the heart of the opioid crisis. Next to West Virginia, it has some of the highest heroin use in the country. That’s most of what I see — heroin, with a little cocaine thrown in every once in a while.
There’s not much in the way of meth here; that’s more of a rural South and Southwestern thing. But regardless of the drug, the method of delivery is the same, as are the effects on the body. People are careless about cleaning their skin and their needles when they inject. Bacteria colonized on the skin enters the body through the venous system and sets up shop on the valves in the heart- mostly the tricuspid and mitral valves, but sometimes the aortic valve too. We can remove the tricuspid valve and leave it out, causing only some mild to moderate symptoms. It is not absolutely essential the way the mitral and aortic valves are.
Endocarditis causes damage to the valves when bacteria form little clusters on the leaflets of the valve — the flaps of tissue that open and close, regulating the flow of blood flow through the heart. The infection can burrow into the wall of the aorta, requiring replacement of the entire aortic root. Left untreated, many of these people will die.
Last year, I assisted on the first 8.5 hours of an 11-hour surgery on a woman not yet 30 years old who was having her third open heart surgery. She almost died on the table and it is truly by the grace of God and the skill of the surgical team that she did not. Every so often, I check the obituaries online to see if she shows up. Sometimes we find out months after their surgery that they died.
Sometimes they use during their post-op stay and arrest in the hospital, which happened to a patient of mine a few months ago. I came in around 6:30 a.m. to discover that she had died in the middle of the night after taking her heart monitor off and overdosing on something someone brought her. The staff did CPR for 20 minutes and called it. She was younger than me.
Often these patients don’t have insurance and their very expensive hospitalizations are courtesy of the dear taxpayer. Fortunately for these patients, we do not yet have a single-payer system that would ration the care they get. Instead, they get chance after chance, surgery after surgery.
I struggle with this. From a pragmatic standpoint, it is ridiculous to ask the taxpayer to foot the bill for multiple open heart surgeries and the subsequent six weeks of skilled nursing care they will need after their surgery for ongoing IV antibiotics. Especially if they just go home, start using again, and die a few months later. But from a Judeo-Christian standpoint, the need to show compassion and try to heal the way the Great Physician heals compels me to want to give these patients a chance … and another … and another.
Do we continue to give people unlimited treatment, or do we cut them off after a time? Are we being compassionate caregivers, or are we just being crazy by repeating the same action but expecting a different outcome?
There is disagreement amongst the surgeons I work with as to our moral obligation to operate. Some feel operating is a bad idea and call in an ethics consult; others feel that you should always operate even if the patient tells you they have no plans to quit. One large hospital in a neighboring city has a one and done policy — they will not perform redo valve replacements/repairs on people that reinfect themselves with ongoing IV drug use. I truly don’t know what the solution is.
Help me out, folks. My empathy is struggling. And I’m tired from all these long surgeries.Published in