They came in within days of each other. Each patient was young, well dressed, and employed. The malady they shared was simple, in a sense, but not straightforward.
The first was a 44-year-old executive. While he'd stood shaving that morning, his right arm had gone limp, and to his amazement he suddenly couldn't speak. His legs still had enough power to propel him out of the bathroom and into his wife's arms. Panic-stricken, she dialed 911. Lying on the stretcher in the emergency room, he looked shaken and pale--but sheepish somehow.
"Mr. Woods, can you understand me?" I asked.
He nodded. "Yuh." "Your right arm is weak?"
"Squeeze my hands."
His right hand gripped my fingers.
"Not bad," I said. "Does it feel stronger than it did a little while ago?"
Again, he strained to speak. "Yuh." Then he shook his head, sad and disgusted at the same time. Stroke victims often remain eerily quiet, as if to make everything all right again they mustn't attract attention. Mr. Woods, though, kept sitting up on the stretcher, swinging his legs over the side, trying to shake it off.
"Mr. Woods," I continued, "I need to ask you some questions. They may seem personal. Okay?"
He nodded and his jaw clenched. He could see it coming. I hoped I didn't sound like an interrogator.
"Have you ever used cocaine?"
It is possible for a 44-year-old to have a stroke, but with no history of hypertension or smoking, it's decidedly unusual. Unless cocaine is involved.
Mr. Woods's head trembled a bit, then he looked me in the eye.
"Uh, hm," he muttered.
"When was the last time?" I asked.
Just then, his wife walked in.
"This morning?" she cried. "John . . . you said you were clean!" She turned to me. "He did the program and said he was clean. For six months." She spun back to face him. "Oh, God, you promised."
Momentarily, I panicked. Mr. Woods's confession was, by rights, confidential. I had not protected him.
"You lied to me, John," Mrs. Woods said slowly, almost in awe. "That whole time . . . you were never clean, right? I waltzed right through it. While you snorted up behind the bathroom door. Right under my nose." She laughed then, appalled at her own bad joke.
Mr. Woods, to my guilty relief, took it quietly. He sat defenseless, stripped of words.
Finally, he contorted his face into a "Sorry." His wife sat beside him and took his hand. "Never. Never again?"
Mrs. Woods felt duped, but she is by no means alone. Doctors, especially we emergency room doctors, pride ourselves on squeezing the truth out of rocks. We know when stories fit and when they don't, and we don't stop asking questions until they do. But I work in New York City; it's boom time here, and drugs chase money. Heroin seems to be the rage among the slim and fashionable, though reliable numbers are sparse. Cocaine was such an emblem of the go-go eighties that in 1985 the United States reported 5.7 million users. In the dozen years since, that number has dropped by more than two-thirds, but ominous signs of a comeback are in the wind: for the first time since 1985, cocaine and crack use among high school seniors is rising, from 9 percent in 1995 to 12.6 percent in 1997. In 1996 we "imported" 240 tons of the stuff.
But who knows how much is really out there? My emergency room cares for half a dozen young professionals a day who rush in with shortness of breath, chest pain, and pins-and-needles sensations in their arms and hands--all the symptoms of a panic attack. But cocaine can trigger an identical sense of choking doom. We always ask, and they always deny. And then I meet a Mr. Woods. And I think maybe I'm the dupe. Luckily for him, it looked as if his stroke would be transient, as happens when the body's own dissolving system takes on the clot in a brain artery before permanent damage is done.
Three days later, a stocky 40-year-old woman, outfitted in the latest take-no-prisoners Wall Street fashion, came howling into the emergency room.
"My chest," she screamed.
There was no getting near her. The medics filled us in on what had happened.
"She's at her office. Suddenly clutches her chest and keels over. Co-workers say she didn't lose consciousness. She has no heart problems, and as far as they know, doesn't smoke, drink, or do drugs."
Ms. Sims was out of control. She thrashed and twisted on the stretcher as if trying to get out from under a jackhammer. It took six ER staff members to undress her, start an IV, and run an electrocardiogram, a recording of the heart's electrical activity. My partner that day, Susan Woo, showed me the tracing.
The ST segments were abnormal. An ST segment is the flat part of the ECG between the rs spikes (the ventricles' forceful contraction) and the T wave (a small bump that represents the heart's electrically resetting itself). When coronary arteries choke off and heart muscle is starved for oxygen, the ST segment lifts like a sheet in the wind because injured heart cells conduct electricity differently from healthy ones. Ms. Sims's were up: wavy and unhealthy looking, though not clearly denoting a full-blown heart attack. A heart attack in a woman her age--with no other risk factors--would be very unusual. Her ECG wasn't giving us a clear answer, and there are many conditions--problems in the lungs, for example--that can cause severe chest pain. Knowing her history would help us decide the likelihood of a heart attack and how aggressively to treat it. Susan parked herself at the bedside and shouted above the din, "Ms. Sims, do you use cocaine?"
"No! No!" her patient shouted back.
"This is very important. You may be having a heart attack. To treat you properly, we must know more. We must know anything that might put you at risk. Have you used cocaine recently?"
"No! I told you. No! Oh, God, the pain. Make it stop. Please!"
Cocaine-induced heart attacks are treated like any others. Susan ordered high doses of nitroglycerin, which relaxes coronary arteries and allows more oxygen-rich blood into the heart muscle. In addition, nitroglycerin decreases blood pressure and the amount of work the heart has to do. But it still made no sense: Why should a healthy, young, nonsmoking woman have a heart attack? We repeated the ECG. The ST segments were changing, reflecting, perhaps, the beneficial effects of the nitro.
"I'm treating her as if it's real. Beats me, though," Susan said, shaking her head. The story didn't fit. But we would treat first, get answers later.
Cocaine, as everyone knows, is a stimulant. For more than a thousand years, the Indians of Peru and Bolivia have chewed raw coca leaf, the source of cocaine's active ingredient, to ward off hunger and fatigue. Used in any of its modern refinements--whether smoked, snorted, or injected--cocaine produces a short but very intense euphoria. Crack, the smoked form, hits with such an overwhelming but brief "rush" that it can trigger a relentless craving: users can go on binges that last an eye-popping 36 hours. Such is cocaine's power that I once watched in helpless awe as two close friends--both disciplined, successful, hardheaded professionals--got desperately hooked. Although they eventually managed to kick the habit, they had fancied their wills to be as rugged as 12-inch armor. They held up to cocaine like Saran Wrap to a howitzer shell.
"It's like nothing you've ever imagined," one told me, in the manner of one biochemist to another. He wasn't making excuses, just explaining.
Cocaine achieves its euphoric effects by prolonging chemical interactions in the tiny gaps between nerves, or neurons, in the brain. Neurons, unlike wires, don't actually touch. They are separated by infinitesimal gaps, where signals pass from one neuron to another. Normally, neurotransmitters--brain chemicals like norepinephrine, adrenaline, and dopamine--are released from a neuron, cross the gap, and bind to receptors on another neuron. After doing their job, the chemicals are released back into the gap, to be swept up and used again by the first neuron. Cocaine interrupts that cycle. In effect it slams the pedal to the metal and holds it there.
The drug is especially seductive because it acts on--and heightens the response of--the same neurons that allow us to experience ordinary sensual pleasure. Some antidepressant drugs work in a similar fashion--and thus affect mood--but in a far more gradual way. There is nothing gradual about cocaine: it jolts neurons like Krazy Kat plugging his tail in a socket. The brain's pleasure centers go wild, but supercharged neurons also zap the heart into overdrive and blast blood pressure through the roof.
Cocaine is best known for its mental effects, but blood vessels take the hardest beating. Normally, nerves fine-tune arteries to relax or constrict in response to organ demand. Eat a big meal and your intestinal arteries open up. Start jogging and the flow gets diverted to your calves and thighs. Cocaine preempts all that. It shouts, "Constrict!" so forcefully that any part of the body--brain, heart, kidneys, lungs, or muscle--can lose its blood supply. Strokes, heart attacks, muscle necrosis, kidney failure, intestinal perforations, and lung malfunction can all result. What's more, the abnormal squeezing (plus other, probably immune-mediated, effects) corrodes and inflames arterial linings to the point that blood clots and burst aneurysms become a lethal probability. Fill your system with cocaine and you might as well be dripping acid in your arteries.
Vascular disease is the greatest killer in industrialized societies. But it's supposed to afflict the old, not the young. Cocaine blurs that distinction, so whenever a young person comes in with a stroke or a heart attack, we always ask.
Susan found me a few days later.
"Remember Ms. Sims?" she smiled ruefully.
"Sure. Is she okay?" I asked.
"Pretty much. She ruled in for a heart attack. It was real." Susan shook her head. "And her drug screen was positive for--guess what?"
And then there was Megan. Blond, plump, and 22, she looked like a rosy-cheeked poster girl for the Dutch Dairy Farmers' Guild. She sat on a chair, her eyes darting about and her chest heaving. The triage nurse had figured her for another panic attack. I walked over.
"Megan Sutherland?" I asked, reading off the chart. "What's the matter?"
"Any chest pain?"
"It's squeezing, like a tight--Oh, Jesus, I can't breathe--band around my ribs."
Some panic attack, I thought. We got her into a cubicle and a gown. After a quick exam, my concern grew. She denied drug use, of course. But she was on the pill and had recently had an abortion--two predisposing factors for a pulmonary embolus, a blood clot to the lungs.
"And you're sure," I repeated for the fifth time, "no drugs recently?"
"Marijuana. Over a year ago. Am I going to be okay?"
"Of course," I soothed. "But I need to check your blood gas, take blood from your wrist artery and see how well your lungs are getting air."
"You're worried about a blood clot?"
"Oh, Jesus. I was at work. It came on so suddenly. Like a kick in the chest."
Megan's blood gas, the measure of oxygen and carbon dioxide in arterial blood, was borderline normal, as was her chest X-ray. No help there, though. Not all pulmonary emboli show up on these tests. Grossly abnormal results would have prompted a million-dollar workup to pin down the clot's location, but these left me at square one.
"Listen," I began, all kidding and sympathy drained from my voice. "I'm about to send you for some very expensive, invasive, and possibly dangerous tests. You may have a clot in your lungs, but your symptoms aren't clear-cut. I need to know. This is confidential and won't go on your record. Please tell me if you use cocaine."
Megan eyed the distance between us; it loomed like a Himalayan crevasse. She decided to jump.
"A couple of lines. This morning."
"How many?" I pressed.
"Couple more after I got to work."
"And then your heart started racing? And your chest got tight?"
She looked at me and nodded, seeming suddenly unburdened.
"Thanks for sharing," I said lightly. "Your symptoms are due to the cocaine. They'll wear off."
"But what about my insurance? I just started this job. What if they find out?"
"The information is confidential. And you did indeed have panic-like symptoms. But you've got to promise me one thing."
"What?" she sighed, expecting the usual "just say no" lecture.
"Don't ever, ever, ever lie to a doctor again. Deal?"
A week later, a 39-year-old lawyer came in, dragged by his girlfriend and his best friend.
"Doctor," the friend cried, "he called and I freaked. I know what he sounds like when he uses. This was the worst."
The patient interrupted. "I did half a gram. Then wham! Paranoia. I thought the cops were breaking down the door. I downed the rest of it, another half gram. I'm out of my mind."
"What else did you take?" I ventured.
"These." He clutched half a dozen vials of the latest Prozac and Valium spin-offs, heartbreaking evidence of one man's plight and a profession's unconscionable belief in tomorrow's perfect panacea.
The lawyer's vital signs and ECG were okay. I watched him for a couple of hours; he only needed reassurance. Finally, he felt he could brave the world again. On her way out, the girlfriend whispered a soft "Thanks."
I told Susan the latest.
"Remember in Diner," she said, "when Mickey Rourke says to Kevin Bacon, ëYou get the feeling there's something going on we don't know about?'"
I held up an empty hand, imitating Kevin Bacon.
"And that doesn't even count the stuff we don't know we don't know yet."