Doug’s mother grabbed my arm. “What is wrong with him?” she pleaded, tears now welling up.
“Don’t worry. We’ll do the tests he needs.”
A CAT scan showed nothing (again). Minutes later, Doug started thrashing and breathing quickly, as if the breathing tube were gagging him. Good sign. Was he waking up? I deflated the cuff and pulled the tube. Coughing until he turned red, he tried to sit up, popped his eyes open, then fell back. Abruptly he resumed breathing very quickly, stopped for a full minute, then revved up again.
“Is that Cheyne-Stokes breathing?” the nurse asked me. This ragged, stop-and-start breathing pattern—so distinctive it has its own eponym—indicates a malfunction in the brain stem’s breathing center. I had seen it most recently in a patient with lupus-induced brain inflammation. He had died.
The toxicology screen came back clean: No alcohol, no Valium, no cocaine. And the rest of Doug’s blood work was stone-cold normal. Stumped, I phoned a member of the intensive care team. “Twenty-five-year-old man,” I began. “Unexplained coma, maybe seizures. Might need a spinal tap. On the positive side, neck’s supple, no fever, no white count. Either way, he needs to be in the ICU.”
“OK,” the junior resident said. “But please call our attending. She has to approve.”
Two minutes later I had the attending on the phone. “Sara here.”
“Sorry to sound so vague,” I said, then recapped the story.
Silence on the other end. Finally she asked, “Is this kid on GHB?”
“Family denies drugs,” I said, instantly hearing how weak that sounded. “Idiot!” I thought to myself. “I’ll call you back,” I answered aloud. I wanted to slam down the receiver.
I cornered mom and sister. “Sorry, but we have to know this: Did Doug do GHB last night?”
Mom did a double take: “What?” But a look flitted across the sister’s face.
“Please ask his friends specifically. Tell them it’s life-or-death.”
Gamma hydroxybutyrate (commonly called G, liquid ecstasy, Georgia home boy, or cherry meth) is to rave parties of the new millennium what cocaine was to Wall Street of the 1980s. A natural brain neurotransmitter, GHB is a stimulant in small doses. Take an extra hit and it is said to bring on a warm, dreamy feeling, with some sexual arousal thrown in for good measure. As a recreational drug, it enhances the hypnotic, techno-music-driven, quivering state that defines rave parties.
The catch? At higher concentrations GHB binds to the GABA brain receptors, just as Valium does. This interaction produces GHB’s signature effect: lights out, like walking into a Mike Tyson uppercut. Worse, GHB’s dose effect is wildly unpredictable. A tad too much and you can go from life of the party to 911 emergency. (GHB was used as an anesthetic in the 1960s but was discontinued precisely because dosing was so touchy.) Little wonder that it has become a leading cause of drug-induced coma and ranks second among all illegal drugs in requiring emergency consultations. Throw in alcohol—which competes for the same liver enzymes that metabolize GHB—and the duration and severity of the drug’s effects zoom off the charts.
Side effects of GHB overdose run the gamut from vomiting, muscle spasms, and seizures to slow heart rate and cardiac arrest. Since its rise in popularity in the 1990s, GHB has killed hundreds. And it is highly addictive: Some abusers need a hit every two hours. Withdrawal after chronic use is particularly nasty. Delirium and life-threatening agitation can flare for weeks after GHB is stopped.
GHB has also gained notoriety as the “date-rape drug.” An odorless, colorless liquid easily masked by a cocktail, it is quickly metabolized and not detectable in routine blood and urine tests. A specialized lab might pick it up, but only by analyzing an immediately obtained urine sample. GHB doesn’t even have to knock a victim out. At a sub-KO dose it can induce amnesia, arousal, and a passive, compliant state of mind.
The sister returned. “The friends fessed up,” she said with a brisk, grim nod. “They did some GHB last night.”
Mom just stared. Then her shoulders sagged.
I called Sara back. “Bingo. And thanks for turning my brain back on. That ‘second episode’ malarkey had me going.”
“You’re welcome,” she replied graciously. “My husband’s a cop. He’s seen a lot of it lately.”
I turned back to the family. The fight with the insurance company over getting an MRI? The kid watching his mom go to the mat for him—for a lie? Then doing it all over again?
I raised my eyebrows at the sister. Her gaze went opaque. Who knew what went on here? I wondered.
The good news was that Doug didn’t display any signs of chronic GHB use, and once this dose of the drug was out of his system, he would be none the worse for wear.
“He should wake up in a few hours,” I reassured his mother. “He’ll be OK.”
“No he won’t,” she muttered, her voice fierce again.
Tony Dajer is chairman of the department of emergency medicine at New York Downtown Hospital in Manhattan. The cases described in Vital Signs are real, but names and certain details have been changed.