COLORADO SPRINGS — Lisa Seiling was playing with her dog in Palmer Park here one afternoon in early July when pain that had been lingering in her chest for several weeks suddenly became unbearable.
“It just felt like someone was stabbing me right in the chest and the lung,” she said. “I grabbed my chest and I was trying not to breathe because every time I would inhale, it would hurt so bad. And then I dropped to the ground.”
When Seiling, 27, came to at UCHealth Memorial Hospital Central in Colorado Springs, the diagnosis was grim: Injecting heroin had caused an infection requiring immediate open-heart surgery.
She had endocarditis, an infection of the inner lining of her heart and valves that is rare in the general population but that doctors in Colorado and across the U.S. say they are seeing in rising numbers as injection drug use increases amid the nation’s opioid crisis.
And with some patients unable to stop using needles, doctors are faced with difficult questions about whether to continue operating on them or allowing them, in some cases, to die.
Endocarditis is among the most serious complications of injecting drugs like heroin or methamphetamine. Needles can introduce deadly bacteria into the bloodstream where they travel to the heart and grow, damaging valves and putting patients at serious risk of stroke.
Endocarditis is not tracked by state health officials, so it’s difficult to say exactly how much cases linked to intravenous drug use have increased in Colorado in recent years. But doctors interviewed by The Colorado Sun said it’s a symptom of the opioid epidemic that is becoming frighteningly common.
“You see this all over the country now,” said Dr. Peter Walinsky, senior medical director for cardiothoracic and vascular surgery at UCHealth Memorial Hospital Central in Colorado Springs. He was the surgeon who operated on Seiling.
“This is a national health crisis, really, with the opioid epidemic,” he said. “It’s a potentially life-ending event, no question about it. If you get bad endocarditis, even if you are treated for it, you can certainly die. And we’ve certainly seen people whose hearts are so infected that even with surgery they die. Even if you survive the surgery, it is a life-changing event.”
Treating the condition often requires an expensive surgery that involves opening up a patient’s chest and fixing or replacing their heart valves.
Surgeons once saw such infections among people injecting drugs only a handful of times a year, but now there’s a steady stream of patients.
For instance, across Centura Health’s 13 hospitals in Colorado and two in Kansas, the number of patients with endocarditis related to intravenous drug use jumped to 66 cases in 2017 from four in 2012.
In 2012, injection drug users accounted for just 2 percent of the endocarditis patients at Centura Health’s hospitals. They now represent nearly a third of that population.
There’s almost no way to prevent bacteria that can cause endocarditis or other serious infections from entering the bloodstream during IV drug use.
Even if someone who has a substance abuse disorder obtains clean needles, the heroin or cotton balls and water they use to prepare the substance before shooting it into their veins can be tainted.
And the problem is made worse, doctors say, because patients who are injection drug users, like Seiling, often have no idea of the risks.
“They just don’t have any idea whatsoever that this can even be a possibility,” Walinsky said. “‘It can affect my heart?’ Why would that ever occur to them?”
Surgery to repair a heart damaged by endocarditis can cost up to $100,000 and take up to eight hours. Patients require six weeks of intravenous antibiotics that must be administered in the hospital. The patients often are uninsured, which means hospitals carry the costs of surgery and in-patient treatment.
Many of the endocarditis cases Colorado doctors are seeing originate from rural areas, where local medical professionals sometimes don’t have the expertise or tools to identify the infections.
Seiling, who is covered by Medicaid, was in surgery for about three hours as Walinsky repaired her mitral valve.
And doctors say it’s also not uncommon for patients to be using drugs even while they are in the hospital awaiting surgery — which is part of why treating them can be so difficult. One surgeon interviewed by The Colorado Sun said he has had endocarditis patients disappear from their hospital rooms only to return clearly intoxicated.
The problem has become so prevalent that the Colorado Department of Public Health and Environment is looking at ways to track endocarditis in the hopes of launching a campaign to cut down on the number of cases.
“We’re still very much in the middle of what I’m calling enhanced surveillance,” said Dr. Alexis Burakoff, a medical epidemiologist with the communicable disease branch of CDPHE.
CDPHE does know that certain infections, like Group A streptococcus — which can cause endocarditis and other serious internal infections — are on the rise among IV drug users.
The number of life-threatening invasive Group A streptococcus cases among people who inject drugs jumped to 34 in 2017 from three in 2013, according to statistics collected in Adams, Arapahoe, Denver, Douglas and Jefferson counties.
Surgeons say the IV drug users they operate on frequently wind up back in the hospital with reinfection because they’ve continued to abuse substances. Once you’ve fallen ill with endocarditis, it’s easier to become reinfected.
That has led some doctors to warn patients that they will perform the surgery just once.
“They told me if I kept using after this it wasn’t ‘if’ but ‘when,’ ” Seiling said. “I was going to get the same infection. It’s going to kill me.”
The warning can be a tough for patients to accept. And it can be difficult for doctors — cognizant of the resource drain that endocarditis surgeries present and the danger such operations can pose to medical staff exposed to infection — to deliver.
“It presents a very challenging ethical situation,” said Dr. Joseph Cleveland, an adult cardiac surgeon who has been practicing for 18 years at University of Colorado Hospital in Aurora. “In general, and within our group of six heart surgeons that practice here, we’re pretty consistent that we’re willing to go to bat for somebody the first time and say, ‘Listen, this is your wake-up call.’ ”
He added: “I think all of us have had very frank discussions with patients.”
Cleveland recalled the case of a woman in her early 20s, who had received surgery to repair endocarditis damage and stayed clean several years before showing up again with a reinfection.
Doctors at University of Colorado Hospital decided to operate on her another time, but within a few months she was back again with another infection after relapsing into substance abuse. She later died.
“That was my epiphany of realizing, ‘This is such a terrible problem,’ ” Cleveland said. “She stands out to me as the one who really shook me.”
Dr. John Mehall, a heart surgeon who practices at Penrose-St. Francis in Colorado Springs, said he had a patient return reinfected a few years after having heart surgery because of endocarditis. She swore she was off drugs, and he tested her regularly for a matter of months — every time the tests came back negative.
Then, right before the surgery, he did a final, random screen that came back positive. The second operation was canceled.
“I would say it’s pretty common,” Mehall said of patients returning with a reinfection. “Very few of these patients, I think, actually kick their drug habit. The reality is the overwhelming majority of them don’t have the resources that can pay for a drug rehab program. That’s a huge global issue.”
Mehall also treated a pair of teenage sisters who fell ill with endocarditis from injection drug use. Both were surgically treated, but eventually they relapsed, returned with reinfections and died.
They were both younger than 18.
“A lot of us who took care of them really thought ‘God, these could be our kids,’ ” Mehall said.
That’s why doctors like Memorial Hospital’s Walinsky are willing to try at least once.
“I have children,” he said. “My oldest daughter is 22, and I’ve done (surgery on) plenty of girls her age or younger. What do you tell the father or the mother who are standing there next to the bed when their kid is dying? Do you tell them ‘No, we’re not going operate on you?’ Or do you tell them, ‘Look, this is a bad problem. You guys got to get things together here.’ ”
The success cases make it worth it. But Walinsky — who requires endocarditis patients who inject drugs to promise they wont continue abusing substances if he operates on them — said he also recognizes that a patient who continues to use after a surgery likely has a slim chance of ever halting their drug abuse.
“If a sternotomy isn’t enough of a wake-up call to tell you: ‘Quit doing this because it’s bad for you,’ then you’re never going to stop,” he said.
Denver Health hopes to increase the chances of keeping injection drug users from relapsing after they are treated for endocarditis with in-patient addiction treatment during their recovery.
Non-injection drug using endocarditis patients typically can leave the hospital after two weeks of treatment, said Lisa Gawenus, director of outpatient behavioral health services and co-lead of Denver Health’s center for addiction medicine.
But patients who are IV drug users must stay much longer because the port used to infuse them with life-saving antibiotics is a ready access point for illicit drugs.
“For this patient population, they are going to stay in the hospital until the infection is resolved,” she said.
And that presents an opportunity for substance abuse care, Gawenus says. Denver Health is seeking grant money to create a program to treat drug users for their dependance while they are being treated for infections related to their IV-drug use.
“We have to address both disorders simultaneously,” she said. “We can’t just ensure that the infection is resolved and then go to treatment. We have to do those things in a coordinated way.”
Dr. Hermione Hurley, who treats patients for addiction and infectious diseases at Denver Health, said it’s a common-sense solution.
“I think we are really behind the 8-ball and we need to do better,” she said. “I think these are missed opportunities. This is a place we can really improve outcomes to people.”
Seiling first injected heroin when she was 17-years old and living in Tennessee.
She was given the drug by someone at a bar. “I wasn’t scared of it. I don’t know why,” she said. “I wish I would have been.”
Seiling landed in Colorado Springs after a trip across the Rocky Mountain West with her then-girlfriend. She quickly fell in with the wrong crowd. She overdosed once, but said she didn’t think it was a big deal since it was regularly happening to people around her.
The first real health consequence of injecting heroin was when she became seriously ill with endocarditis on July 7.
“It’s scary,” she said. “But kind of a good kind of scary because I’ve been needing something to kick me out of that lifestyle. I don’t have any kids, I don’t have an old grandma that needs my help. I don’t have anything that I’m responsible for besides me. So, having a reason to quit is a huge deal. It’s helpful.”
Her plan was to leave Colorado once her treatment was complete and live with her dad in Maine.
“Right now I don’t have a desire to do it (heroin), and I’m more scared of doing it than anything,” Seiling said, a long scar running down her chest from where surgeons made an incision to repair her heart. “But I’ve been sitting in the hospital, too, and it’s so recent. I don’t know if it’s going to stay that way. That’s my main concern.”
“I’m hoping that it’s easier,” she added. “I’m hoping that it’s easy to stay off of it.”