The patient is “a skin popper.”  She injects heroin into her skin rather than snorting it or injecting it directly into her veins.  Her arms are covered with sores in various stages of ulceration from old scars to open weeping sores. 

example of skin popper
The ambulance crew is there not for an overdose, but for chest pain and confusion.  The medic puts  electrodes on the woman’s chest and does a rapid 12-lead ECG.  The ECG shows huge anterior ST-segment elevations.    The 12-lead is transmitted and then a STEMI ALERT is made to the receiving hospital.  The cath team meets the patient at the ED door, but the doctor is concerned that the patient is having difficulty comprehending the consent instructions and is unable to write her name.  She is sent to the CT scan before being rushed up to the cath lab.  A Stroke Alert is called and as soon as the cath lab team has pulled several emboli out of her occluded left anterior descending artery, the neurology team takes over.  The CT scan revealed multiple septic emboli in the brain as well.  Septic embolic are small emboli filled with pus and bacteria that likely broke away from the vegetation in the patient’s heart values.  The patient suffers, like many drug users who use dirty needles, from endocarditis.  If her heart were a carburetor, the mechanics would throw it out rather than attempt repair it it is so gunked up.


Bacterial Endocarditis

Endocarditis is epidemic in the United States today.  It’s rise mirrors the rise of opioid deaths. While this patient’s demise will not be counted in the overdose death numbers, she is nonetheless a casualty of the opioid epidemic that is destroying people, families and communities across the country.  The woman is very sick.  Too much damage has been done to her heart and brain.  After a discussion with her loved ones, she receives a final opioid — morphine, then she is extubated, and with family at her side, she passes on. 

Endocarditis can come from using dirty needles.  Tell your patients where they can get clean needles.  In Hartford, they can go to the needle exchange van.  Here is the schedule:
Monday – Friday
  • 7:15 AM – 9:45 AM (Park & Hungerford St.)
  • 11:00 AM – 12:45 PM (Albany Ave. & Bedford St. by CHS)
  • 2:00 PM – 2:50 PM (Park & Hungerford St.)
They can also contact the Greater Hartford Harm Reduction Coalition at  860-250-4146.
 In Connecticut, users can purchase 10 syringes at their local pharmacy for about $4.  They do not need a prescription.


  • DM says:


    Kind of an aside but are you seeing any patients presenting with heroin and visine mixed where they dose through eye drops? seen 2 cases this week and was a first for me.

  • medicscribe says:

    Interesting. No, I have not heard of this, but will ask around.



  • Ben Chlapek says:

    I stand back and watch the second and third order effects of the movement and belief that “all opioids are evil” that has a grip on our country. Low dose hydrocodone for pain management worked for many, many people. However, the monitoring of physicians, pharmacies, and patients by the DEA has raised a huge amount of reluctance to deal with the huge micromanagement of physicians and their prescribing drugs prudently for the management of pain. With the low dose, oral administration of tried and true opioids used prudently by the majority being “demonized” the use of heroin has increased exponentially, leading to horrible diseases and illness like endocarditis. Sometimes, we are our own worst enemies. Good luck and more luck to all of the people living in pain who were once managed by physicians who could practice medicine without micromanagement. My $0.02.