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On February 2, 2014, Academy Award-winning actor Phillip Seymour Hoffmann was found dead with a needle in his arm and syringes and packets of heroin in his room. How does a heroin overdose kill a person?
Anesthesiologists are uniquely qualified to answer this question. Anesthesiologists administer intravenous narcotics every day, because narcotics are important pain-relieving drugs in anesthetic care. If an anesthesiologist is attending to you while narcotics are injected into your bloodstream, you are safe. If an addicts chooses to inject narcotics into his or her bloodstream while they are alone in their apartment, they can die.
Heroin (diacetylmorphine or morphine diacetate) is in the same category of drugs as morphine, Demerol, and fentanyl. Heroin is prescribed as a controlled drug in the United Kingdom for use as a potent analgesic or pain reliever, but the drug is not approved for any medical use in the United States.
Within minutes, injected heroin crosses from the bloodstream to the brain. Once inside the brain, heroin is metabolized to the active drug 6-monoacetylmorphine (6-MAM), and then to morphine. Each of these chemicals binds to opioid receptors in the brain, which results in heroin’s euphoric, pain relieving, and anxiety-relieving effects. The duration of a single dose of heroin is 3-4 hours.
In addition to sensations of euphoria, calmness, sleepiness, pain relief, and blunting of anxiety, narcotics cause significant decrease in both the rate of breathing and the depth of each breath. This respiratory depression can be lethal, especially at higher doses.
In all acute care medicine, whether in the operating room, the intensive care unit, the emergency room, or the battlefield, physicians follow the mantra of “Airway-Breathing-Circulation.” A doctor’s first priority to keep the upper airway open, using a variety of techniques including jaw thrusts, extending the neck, inserting an oral airway, or placement of a breathing tube. A doctor’s second priority is to assure that breathing, or ventilation, is ongoing. The doctor may assist breathing by delivering breaths of oxygen into the patient’s lungs via a ventilation bag (e.g. an Ambu bag). A doctor’s third priority is to assure that adequate circulation, or heart function, is ongoing.
If a large dose of narcotic is administered, breathing may cease or become so obstructed by the tongue and soft palate that no air moves in and out through the lungs. If an addict injects heroin while alone in their home, and they lose consciousness, their airway may become obstructed and breathing may cease. Oxygen levels to the brain and heart will plummet. After only minutes of inadequate oxygen, their heart will arrest and the addict will die.
Simultaneous usage of additional central nervous system depressant drugs, such as alcohol, benzodiazepines (Xanax, Valium, Librium, Ativan), or narcotic pills (oxycodone, Vicodin, Percocet) along with heroin can intensify the respiratory depression, and place the addict at even higher risk of ineffective breathing and resultant cardiac arrest.
Tolerance to heroin develops quickly, and users require more of the drug to achieve the same effects. This prompts addicts to inject increasing doses to achieve the desired “high,” with the attendant risk that each increased dose will be excessive, and lead to airway obstruction, inadequate breathing, and cardiac arrest.
Intravenous heroin usage carries additional risks, including viral infection (hepatitis or AIDS) from contaminated needles, bacterial infection of the heart valves (bacterial endocarditis), reactions to contaminants (e.g. starch, talc, or other drugs) in the heroin preparation, localized infections (abscesses) at the site of injection, and powerful withdrawal symptoms on cessation of heroin use.
But cardiac arrest from respiratory depression looms as the most frequent cause of sudden death in heroin addicts.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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