Most Unforgettable ER Night Shift Ever (eBook)

Chapter 2

Respect the Sex Organs
7:17 p.m.

“Doctor, an ambulance is pulling in with a seizure patient. We’ll take him into Treatment Room 2. The medics sound rattled. We didn’t respond to their first call and the patient didn’t stop seizing until after they gave him a third benzo,” Nurse Sally reports to me.

“Thanks. Turn up the EMS radio. The damn thing is either too quiet or way too loud, but we can’t afford to miss calls. I’ll meet them at the ambulance bay,” I reply. Usually, seizure patients are very straight forward. Witnessing someone seize is alarming, but the majority of the time it is far from life threatening. Over one percent of adults have epilepsy. In addition, up to five percent of children will experience a febrile seizure and an equal percentage of alcoholics will have a withdrawal seizure sometime during their life. Paramedics, like most emergency medical workers, usually get a bit desensitized to seizing patients. I wonder why they are rattled?

I meet the two paramedics at our now open large entrance doors. The ambulance bay is a ramp covered entrance that opens up smack dab in the middle of our department right in front of the main desks. In seconds, we can wheel a gurney into one of our large trauma rooms. Both medics look frazzled. This is the final run of the day for Kim and Dan. The paramedics do 12 hour shifts like I do, as do most of the nurses. Their foreheads are dripping sweat. “Give me the low down!” I ask, looking down at the patient. I don’t wait for a response as I do a quick sternal rub and see if I get any response to the inflicted painful stimuli. Nothing! He is a large adult male probably around thirty years old, roughly six foot and little over two hundred pounds.

“Well, Doc, he and his girlfriend just finished having sex when he grabbed his head and started seizing. He only stopped when we pulled up, after already giving IV Ativan, Valium, and Versed,” Kim answered.

Damn! “No past seizure history? How long total before he stopped seizing? Girlfriend on the way?” I ask. I have an annoying habit of blurting out multiple questions before the first question is answered.

“No prior seizures Doc. Um she said he was shaking non-stop for possibly thirty minutes before we got there and another 20 minutes in route.” Witnesses over estimate seizure time unless they actually time it with a watch, but this patient’s duration is extreme. “She was right behind us driving as fast as Dan,” answers Kim, referring to her partner, who usually drives like a bat out of hell. They both understand that this is a rare life-threatening seizure patient. Now I know why they were rattled. This was not a simple recurrent or withdrawal seizure. This patient was in severe status epilepticus. Status epilepticus is a seizure over five minutes or multiple seizures in a five minute period without returning to normal level of consciousness between episodes. This patient is critical and I have to find out the cause and stop the seizures from continuing.

The nurses are hooking him to the monitor as I start spouting off orders. “Tell respiratory to get down here with a vent and tell CT I want a head CT as soon as I am done intubating. Also, I want both Dilantin and Versed drips started, full labs, and drug screen. Sally throw in a quick foley,” I order. The first thing to do with an unstable patient is to stabilize. Looking at the monitor, I am pleasantly surprised to see a stable blood pressure and an understandably fast heart rate. In the ER, we keep it simple and focus on the ABCs—airway, breathing, and circulation. Having a good blood pressure and solid heart rate establishes the C, or circulation. I need to start at the beginning or A, the patient’s airway. A seizing patient can aspirate or as in this particular case and his extended seizure duration, could stop breathing all together. I need to protect this patient’s airway. Intubating a patient refers to placing a tube into the trachea to provide artificial ventilation. Once the tube is placed, we can use a bag that’s connected to an oxygen source that a person has to manually squeeze or use a ventilator unit that works hands free once we set in certain parameters. The medications I ordered are anti-seizure drugs, as I need to make sure his seizure activity doesn’t return. While all this is going on, my brain is working out possible causes or etiologies for his seizure. I need to know why he is seizing before I can provide a definitive treatment. The one glaring possibility that tops my differential diagnosis list is terrible. An acute brain bleed can present as a new onset seizure, especially severe status type. In fact, one of the most famous emergency medicine board questions described a young male patient with the sudden worst headache of life after masturbating. What is the likely diagnosis? The answer is a subarachnoid hemorrhage! The exertion act causes an unknown brain aneurysm to rupture. The brain bleeding then causes the seizure. My patient was having sex and grabbed his head before his seizure started. Shit! People joke about kicking the bucket while having sex, but not at thirty years old.

I am at the head of the bed and instruct my nurse to give some IV Succinylcholine, a neuromuscular blocker, the fancy name for a paralytic medicine. Waiting for him to become completely paralyzed, I am standing armed with an endotracheal (ET) tube and a laryngoscope. A laryngoscope is a metal device that allows visual inspection of the vocal cords to allow proper placement of the ET or breathing tube. In almost all emergency departments today, the old metal laryngoscopes are collecting dust as plastic fiber optic ones with high quality anti-fog cameras allowing a monitored perfect anatomical close-up picture have replaced the old standbys. I easily position the laryngoscope with my left hand, and with my right hand begin to slide the ET tube through the visualized vocal cords. Suddenly, my patient starts seizing again. Leaving the ET tube in place, I retract the laryngoscope seconds before his teeth clench, saving him a mouth full of chipped teeth. His entire body is convulsing and I am about to yell at my nurses for being too slow with the anti-seizure drugs. Lucky for me, I looked up and saw the hanging IV medications before opening my big mouth and trying to lay blame where it didn’t belong. Both Dilantin and Versed drips are not only hung, but dripping into the patient’s nice flowing IV line. What the hell is going on? Most seizures will stop after giving anti-seizure medication. The few exceptions will stop after adding a second medicine. This patient has had four medications that usually terminate seizures often by themselves. “Give him 10 mg of Vecuronium or 100 mg of Rocuronium, whichever one is in the intubation med tray,” I order. Those are two longer acting paralyzing medications.

With the patient intubated, we now have a secure airway and provide the breathing for the patient. A and B of the airway and breathing checklist are completed. Now I can focus on how to abate the seizure activity. Also, I need to get him to CT and don’t want an inaccurate study because of movement. As soon as the Rocuronium hits his vein, he stops shaking. Everybody in the room lets out a long breath. “Quickly, take a chest X-ray and let’s get him into CT. Oh, set up a lumbar puncture (LP) tray at bedside for his return,” I say to everybody, failing to suppress my anxiety. If a brain bleed is seen on CT, I won’t need to do the lumbar puncture. However, if the CT is negative, the lumbar puncture will be needed for multiple reasons. A small percentage of subarachnoid hemorrhages (SAH) can be missed on CT, but diagnosed with lumbar puncture. Also, infection or other neurologic disorders can be deduced from cerebrospinal fluid (CSF). The lumbar puncture, or layman’s spinal tap, is not as scary or painful as people fear. It is a simple procedure of obtaining CSF from the low back. Patients often are placed on their side, a small lumbar area is numbed up, and a hollow needle is inserted to obtain CSF. I have mixed feelings about wanting the CT to give me the answer. If it gives me the answer, my job becomes easier but at the patient’s expense. An aneurysmal brain bleed has poor prognosis. If negative, I may find a less ominous cause, but the investigation will be far from over. The CT scan goes smoothly and I call the radiologist to read the images as soon as possible. “Radiologist on line 1!” somebody yelled. I grab the phone, “Hey it’s Adams, anything on the head CT?” The radiologist on the other end of the line gives me an all clear, completely negative scan report. Great! But what is causing his seizures then? My patient dodged a deadly bullet. Now I need to do my best Sherlock Holmes impersonation. Unlike the medical shows that frequently depict multiple diagnostic dilemma patients, they are not an everyday occurrence. During an entire shift, the ER doctor probably sees only one case that is actually rare or difficult to diagnose. We call the rare cases zebras. In comparison, most cases that present to the ER are horses. If you drove around the country avoiding zoos, how many zebras would you see? On that same drive how many horses would you see? You get the point.

My initial diagnosis is probably wrong, and that is a good thing. However, I now have to do the lumbar puncture and continue searching for answers. “Doctor, he is seizing again!” Betty yells.

“Shit! Repeat the Rocuronium! Also, give him two grams...