The Flip of a Switch

She was already dead when the ambulance attendants rushed her through the emergency room doors. A massive hemorrhage had replaced the area in her skull that was once her brain. I later learned that she was the single mother of two grown daughters and an expectant grandmother. A sister had spoken to her by phone the day before and ‘everything was normal.’ One of her daughters who still lived at home had heard her begin her usual bathroom ritual that morning, but the subsequent grunting and crashing alerted her that something was terribly wrong. In one unheralded instant, this 47 year old woman had become another mortality statistic of cocaine use. Her blood pressure had soared to 250/160. She died quickly and alone. . .with no goodbyes.

Though this woman and I had never met, the next 48 hours would “tie” us for eternity. It was my day to be on call for the emergency room. This meant that all medical patients without a doctor affiliation who required hospitalization in that 24 hour block of time were to be admitted to me. Generally, this task is perfunctory; often no patients even require admission when my rotation rolls around. But, Ms C and I became paired as she was rolled on stretcher from E.R. to ICU–a phone call to my office notified me of this fact. Because she was brain-dead at the time of arrival, her heart continued to beat, but her breathing had stopped before the paramedics ever arrived at her home. Only the mechanical precision of the computerized ventilator provided any oxygenation to this lifeless form who had so recently been a vital human being.

Forty two relatives arrived at the hospital over the next few hours, and signed in at the ICU door as “Immediate Family.” Only in this category would they be allowed through the Intensive Care Unit doors to hold her hand, to encourage her to “wake up”, to begin the awful ritual of saying goodbye to someone who is loved and will never return. It was only through the accounts of these relatives and the blood and urine tests that returned “positive” for alcohol and cocaine that I was able to construct any sensible history in this tragic and brief doctor-patient relationship.

Over the next 44 hours, two separate neurologists and a neurosurgeon saw Ms C in consultation. They confirmed her absence of any reflexes, her fixed and dilated pupils, her lack of response to pinpricks on the extremities or ice water shot into her ear canals. The family members were shown the CAT scan of her head–filled with the black void of blood rather than the gray textures of a healthy, normal brain. They needed some tangible explanation for her lifeless state. And, my role had become interpreter. . .in a sense, the messenger of death. I prepared and comforted the family as best I could, yet the futility of a stranger’s comfort was sensed by us all. The flatline EEG which was obtained late on Ms C’s second hospital day, simply confirmed the brain-death that had been apparent all along.

In the early hours of the morning, Ms C’s blood pressure dropped to critical levels, and her heartbeat matched this precipitous plummet. The family wearily camped in the waiting area were ushered into her ICU cubicle to witness the flip of the switch as her ventilator was silenced. What an unceremonious and premature death for a woman who had obviously been a joyful presence in the lives of those people now gathered around her bed!

Approximately 1% of the American population age 12 and older are current cocaine users. It’s made from the leaves of the coca plant, native to South America, and is almost two drugs in one–blending stimulant and anesthetic effects in one molecule. Study animals addicted to cocaine prefer the drug to food–even when it means they will starve. Frighteningly, the highest rate of current cocaine use is in the 18–25 year olds in this country. The immediate effects of its use are intense euphoria with heightened energy and alertness. But, it’s effect is short-lived. . .creating need for repeated “hits” if one is to sustain such feelings. And, the physical effects include constricted blood vessels, elevated heart rate, respirations, and blood pressure–which can be deadly.

If you wanna hang out you’ve got to take her out; cocaine
If you wanna get down, down on the ground; cocaine.
She don’t lie, she don’t lie, she don’t lie; cocaine.

If you got bad news, you wanna kick them blues; cocaine.
When your day is done and you wanna run; cocaine.
She don’t lie, she don’t lie, she don’t lie; cocaine.

If your thing is gone and you wanna ride on; cocaine.
Don’t forget this fact, you can’t get it back; cocaine.
She don’t lie, she don’t lie, she don’t lie; cocaine. . .

J.J. Cale

The precious and precarious qualities of life are never more apparent than in instances when one sees a life cut short precipitously and prematurely. We take so much for granted. . .leave so much unsaid. . .because “there’s always tomorrow.” Cherish your life; care for your bodies; and tell those people who give value to your existence that you love them.

Stephen L. Hines, M.D.
May 2001