Endocarditis and IV drug use, Sheila's Story

On a cardiac unit, I see all types of heart and vascular diseases, and many of them appear in the same "type" of patient. Peripheral vascular disease is usually in diabetics or smokers; coronary artery disease is often in people who are at least a bit heavier than is healthy; and endocarditis is more often than not a young person who has a history of IV drug use. Endocarditis, an inflammation of heart tissue, is often caused by infection, and people who are often engaging in IV drug abuse risk introducing bacteria directly into the blood stream every time they use. Usually your immune system can fight off invaders, but not always. Sometimes, exposure to bacteria often enough is just too much for the body to keep up with, and the heart ends up infected.

Most of the patients we get with endocarditis are preparing for a replacement of the infected heart valve. Endocarditis can be treated with antibiotics, but we see surgical cases more often. The sad reality is, drug addiction is a hard battle to fight. Whether you believe it is a "disease" or not doesn't change the pattern we usually see: More often than not, these patients get a new heart valve, go home, and end up right back where they started by continuing IV drug use. Eventually, hospitals start denying repeat valve replacements, because if the patient hasn't demonstrated a commitment to caring for a donated valve after a risky surgery, why keep throwing new ones their way that could be used on someone who has demonstrated a commitment to change? It's important to recognize the difference between commitment to change and just saying you're committed to change but not making a proper effort. It's indisputable that fighting drug addiction is a steep uphill battle that often involves relapses, especially if the patient does not have adequate support outside the hospital. For that reason, my manager, Lauren, 5 years ago decided to try to pilot a program for providing support outside the hospital for patients with new valves, and Sheila was who we tried it on.

Sheila was a small, young girl in her mid-20s with a well-documented long history of IV drug abuse. She, like many others, received a heart valve replacement, and then continued her drug use until the new heart valve was diseased as well and she came back. She was in the hospital a long time, so that most of the nurses knew who she was and started to get to know her. Sheila was sweet and polite, always accompanied by her mom, but there was always a bit of a dark cloud hanging over her. We could tell she was struggling, and it broke our hearts to see her return one day with an infection of her recent, new heart valve.

At first, the doctors told her she was out of luck. Many surgeons and doctors and nurses put time, effort, and licenses on the line when they operated on her and gave her a second chance at life, and it was understandably upsetting to see how quickly it was neglected. But Lauren spoke up about how we kept releasing these patients with minimal out-of-hospital support in fighting their addiction. We would give them a new valve, tell them "Good luck, don't do drugs", and send them off. Unfortunately, that's rarely enough to help someone fight a drug addiction, so they would relapse and end up right back where they started. So, the hospital decided to pilot a program in which Sheila would get a second valve, in exchange for her signed commitment to following up with an out-patient treatment plan, to include escorts to rehab meetings and frequent check-ins and education. The hope was that, if the patient was provided with some extra support after being sent home, their chances of successfully conquering their addiction would be much higher. Sheila agreed, signed the commitment, and got her second chance.

At first, it seemed to be working. She complied with the treatment plan, showed up to rehab meetings, and followed through on the steps we had asked her to take to fight relapsing. It was encouraging and exciting to see her stick with it.

Unfortunately, IV drug use is a beast that is hard to fully get rid of, and one day, Sheila just stopped attending meetings and check-ins. We tried to contact her and keep her on track, did whatever we could to support her fight, but it just wasn't enough. She relapsed, enabled by her own mother, and ended up hospitalized once again. Sadly, the doctors had had enough and gave her a few months to live. I don't actually know her current status, but I'm sure by now she's gone unless she found a different hospital willing to overlook the relapses and try again.

The reason this story sticks with me is because I honestly believe there was some potential in that program we were piloting. It may not work for everyone, like it didn't work for Sheila, but I think it could work for some, particularly patients who have children depending on them to get better. I've sat and listened to patients cry and vent about how horrible they feel letting down their kids, how they need to get over their addiction so they can care for their kids for a long, long time and see them grow up. Sometimes I wish we could try the program again. The concept makes sense, and it's better than sending patients off with minimal support. But, as far as I know, we have not attempted it again since Sheila. With the drug abuse epidemic going on right now, maybe it's time to try again....

Moral of the story: Drug addiction is no easy struggle to overcome, and I personally believe we are failing our patients when we discharge them with new heart valves and minimal outpatient support. It's like treating someone with high blood sugar in the setting of new diabetes and then discharging them without prescriptions for insulin or glucose monitoring or education on diet. That's just unthinkable. We always discharge our diabetic patients with copious research, guides, and resources. They don't always comply, but at least they are given what they need to try. Why can't we do the same for IV drug addiction and valve replacement patients?

• Bella, RN