Chapter Eight: Bad Line
Cheryl was a twenty three year old woman when she was brought to the ER at 6:15 on a fall morning in 1993 after enduring several hours of 'seizures' observed by her husband. Her husband frantically described uncontrollable muscle jerking and the patient continued to display a rapid rhythmic jerking of her extremities, trunk, and neck muscles while remaining conscious and able to talk, though in obvious distress. The ER physician at the time, on his last two hours of a twenty-four hour shift, thought this was some kind of psychiatric phenomenon and gave her a shot of Valium and sent her home. She and her husband acknowledged snorting a line of 'crank' (street methamphetamine) during the afternoon before. He stated that they were not regular users of drugs or alcohol. He said he was employed and responsible but that they were going through incredible levels of stress because his sister and her two children were in a fatal auto accident the week before. One of the children survived and was hospitalized elsewhere, wrapped in a 'body cast'. The others were killed. Cheryl and her husband had been dealing with funerals, the nephew's hospitalization, their bottomless cosmic pain, and so when offered a line (linear pile of drug to snort) of recreational substance, they gave in. What are friends for anyway? Some ten hours later, at about one in the morning, this jerking began and after several hours of confusion and distress, they came to the ER. I came to work at 8am, after they had been discharged, but by 11am on my shift, they were back to the ER with more of the same. My nurse Cleo called me with a tone and words reserved for unusual urgency, "come down now, we've got trouble." Relaxing in the on-call room one floor above the ER, plucking my guitar, I snapped out of it and bolted down stairs.
I observed a young woman with a neuromuscular display (uncontrollable physical movement) I had never seen before. As when she first came in, she was conscious and communicative, but her entire body was irregularly twitching with roughly 1/2 second contractions, both extension and flexion (alternately stretched out and then drawn up), including trunk and neck muscles, with no more than one or two seconds between twitches. Her eye, tongue, and jaw muscles were not involved. Her vital signs were normal except for a mildly elevated pulse of about 115. She stated that she did have tingling in her fingers so I checked her arterial blood gases to see if hyperventilation might be part of what was going on. When people hyperventilate, they breathe off their own carbon dioxide, lowering the level in the blood. The blood gas test could confirm this. She had lost her spleen from trauma two years ago (when people sustain major force to the mid-body, the spleen often breaks causing internal bleeding and shock, treatable with life saving surgical removal of the spleen). Her husband was mildly frantic, wanting to know what was wrong, urging me to make her better. Unlike many who live in our community and know me directly or by reputation, these people were new to the area and didn't know me from Adam. They only knew that a gray bearded, older doctor saw them early in the morning (the physician who I relieved at 8am), didn't say much, didn't make her better, and now she's back, 'convulsing', after having done a bad thing (crank), while going through the biggest ringer of their lives. Her husband saw me looking at her, watching this bizarre behavioral display, saying little while trying to get a handle on what was going on, what to do next. I knew that this wasn't a true seizure, and it didn't fit any well described pattern of drug reaction, so, on the advice of one of my mentors from the past, "don't just do something, stand there", I stood there watching, processing. All of my attention was taken trying to sense a toehold for myself. I was unable to tend to the husband, to deal with his fears for his wife. When he demanded that I do something, and repeatedly asked me what was wrong, I said somewhat blankly, "I don't know". I followed this with, "I've been doing this a long time and I've seen a lot of things, but I've never seen this, and I'm really not sure what is going on." I could see that this was of no reassurance whatsoever. I told the nurse to give her a milligram of lorazepam (a Valium type medicine used to control seizures), to cover the possibility of a seizure-like phenomenon, without major risk to her.
A shadow moves slightly in the periphery of my inner vision, a vague figure between two rocks. I turned to look. Only two rocks. A sound of rustling from behind the rocks. Which one? Was it the sound of crackling twigs or leaves? The sound of crunching bone? The sound of the rattle? Predator or prey? Can I move on and ignore the nearly subliminal information or is a predator taking aim?
To my surprise, her blood gases were normal. Carbon dioxide was normal! She wasn't hyperventilating, so I had lost one possibility for simple explanation of one of her symptoms, the tingling in her hands and feet. The rest of her blood tests were unrevealing of any specific condition. Her blood count showed an elevated white blood cell count, consistent with her state of distress and absence of a spleen. I hoped that what I was seeing was not some strange form of septic rigors (a neuromuscular display from overwhelming infection, toxic state). Could I be missing some sort of catastrophic infected encephalopathic state (brain poisoned by toxic biologic products of infection) the likes of which I had never seen or somehow missed in training?
The lorazepam helped quite a lot and as Cheryl slipped into a sleep of relief, I spoke some more to the husband. "Ben, it looks to me like your wife was simply at the end of her rope in terms of stress and the drug just pushed her over the line. When people break, they often display their distress in dramatic ways, to get everyone's attention, which certainly happened in this case. I suspect if she can just sleep this off, she'll be all right. I'm going to give you an oral form of the drug we just used for her to take for a few days. Obviously, snorting recreational substances is out of the question."
In agreement and relief he went out of the emergency department to tend to their five-month-old baby. We observed Cheryl in the ER for two more hours, let her sleep, then discharged her. By that time she had normal vital signs. I gave her a prescription for an oral form of the medication we used and the usual recommendations to call or return for any problems. They left at about 2pm.
The day rambled on with irregular flow of patients with back pain, stomach pain, respiratory infections, ear infections, and a patient from the mountains who knew my wife from twelve years ago bringing us a box full of colorful fall squash in appreciation for care rendered. He was suffering from a very painful peri-rectal abscess. Midway through my performance of incision and drainage of this awful abscess, the ambulance squawk box went off notifying us that they were being dispatched through 911 for a convulsing patient, several blocks away. As the foulest of foul pus drained from the incised wound, I ran my mental Rolodex trying to figure out which of our known seizure patients lived a few blocks away. I didn't have to locate my gray matter file. The next ambulance report was preceded by "we're at your back door" and "this patient was in the ER earlier today". I thought of the line from Butch Cassidy and the Sundance Kid, as they looked back repeatedly at their trackers. "Who are those guys?", only my version was, "what is going on with this woman? What am I missing?" And just after that thought, "what happens if I blow it?" Bear in mind that my immediate resource base, the sum total of physicians in our rural town is a handful of family practitioners, one internist, one general surgeon, and the telephone. The closest competent neurologist is ninety miles away and full motion video fax did not yet exist.
Cheryl rolled in on the ambulance gurney twitching and anguished, followed by a considerably more anguished husband, desperately looking for relief from confusion and suffering. Again, lost for a solid diagnosis, and having less faith that this was a psychoneurotic display (having a primarily psychological cause), I stood by her side, watching her twitch, noting normal vital signs and feeling pressure from the husband for some answers. Repeating that I've seen a lot of things and this is just strange served no use. Ben then asked if she shouldn't be sent somewhere else where there are 'specialists' who might be able to help her. How could I tell Ben that this would almost certainly be a complete waste of time? I've seen enough to know when someone needs to be shipped for a higher level of care, whether for diagnostic or therapeutic resources. I knew that with stable vital signs, normal lab, and absence of more threatening signs, she didn't really need to go anywhere right now. I also knew that the time and energy it would take to arrange this transfer would be greater than either the time or energy it would take to get phone consultation from Poison Control (the San Francisco toxic emergency help line) and institution of some kind of therapeutic/suppressive measures. The bizarre toxic effect of the 'crank' would wear off at some point, maybe soon.
I gave her 1/2mg of lorazepam IV with minimal benefit. Lost and humble, I turned to my able nurse, Cindy, and asked her what she thought. She suggested the possibility of dystonia (a strange, very distressing body movement and muscle spasm disorder which occurs in response to certain medicines, usually drugs used to control nausea). Though that was appealing on the basis of unknown drug ingestion (we do not know the full composition of street drug preparations) and for possibility of dramatic relief with IV Benadryl (curative for this drug reaction), the fact remained that her movement was twitchy, not athetoid (the type seen with dystonia, slow sweeping movements of the limbs and slow writhing of the center of the body), and there was no involvement of the eyes and tongue as is usually the case with dystonia. What the hell, I had nothing to lose, I gave her 50mg of Benadryl intravenously and watched her movements decrease a little. Not much. After several minutes and minimal recovery, I decided to chat with Poison Control. On the way to the phone, Cindy suggested strychnine poisoning. Brilliant! Everybody has heard of street stimulants being cut with strychnine, though I don't know anyone who has seen this, but street lore has its own mythology. The description of muscle spasms in this type of toxicity was much closer to what we were seeing here, though she denied being worsened by sudden sound or other irritation, as is seen with strychnine poisoning.
Poison Control listened to my story and replied that strychnine toxicity would be immediate and would have worn off by now. And, it didn't sound like anything they could explain. The toxicologist stated that they see quite a variety of movement disorders for up to two days after amphetamine (including methamphetamine) ingestion, not correlated with the psychotropic effect (the high), but that most of these are athetoid, not twitchy. She also stated that we might be observing an index case of toxicity (first report of a toxic effect of an unknown substance - a public health issue) and that it would be very important to get a drug screen to check for other substances. She asked if any others had partaken and reacted in a similar way. The husband had taken some and stated that he was getting spasms of his leg and thigh muscles, but nothing close in degree to those of his wife. Great, an index case in my little ER. That was fine, but what to do? I suggested we continue to suppress with benzodiazepines (Valium, lorazepam, etc.) and wait it out. Poison Control agreed. The poison control physician on the phone then consulted with her attending, the head honcho pharmacologist, who added that this could also be a persistent dopaminergic overdrive (overstimulation of one of the brain chemicals) which might be suppressible with a dopamine blocker such as Haldol (a dopamine blocking anti-psychotic medicine). This is exactly what you wouldn't want to use if this was some type of bizarre partial complex seizure (Haldol can increase seizure activity). The ultimate treatment and final diagnosis would continue to be a mystery. It was time to get this patient admitted to the hospital using the drugs to suppress her troubling movements. The problem at hand was how to handle a frightened, stretched-thin husband who by now was pacing frantically.
I had to take things a step further. The patient's husband had no way of knowing that all appropriate care was being done. I had to give him more reason to trust my judgment. I rarely pull out the credentials, but I thought he needed to be able to distinguish me from a less qualified or inexperienced physician who works ER by default, making a few bucks on the side without any particular commitment to the cutting edge of emergency diagnosis and management. I prefer humility, warm informality, and the human touch. But there are times to check the ID. "Ben, I want you to know who I am, who is taking care of your wife in this troubled state. I trained at Stanford and I am a board-certified specialist in emergency medicine. I've taken care of over a hundred thousand patients in my time and I'm older than I look. Even though I'm not sure exactly what's going on with Cheryl, I do know what I'm doing and we will figure this out. You should also know that although I'm not positive what she has, I know very much about what she does not have."
Ben then blurted out, "I just want to know, am I going to lose her too? Is she going to die doc? Is she going to be OK?" Of course! I had missed the point that his fears were completely basic. If she was going to be all right, that is what he needed to know, not the details of differential diagnosis (the list of possible diagnoses arrived at through critical analysis, a formal process in medical sleuthing). I had that information early on, but didn't fully appreciate, in the pressure of the moment, that Ben needed to know that she would be alright in the long run, that she would survive. I could have let him know this, whether I was sure or not. If I were wrong, this mistake in prognosis would have no impact on either of them in the long run. They would be taken up with the task at hand (therapy, coping, and treatment). They would not dwell on being misled by an overly optimistic judgment in the first few hours of a morbid illness. Plus, odds were on my side. I can generally tell if someone is headed for big trouble.
I ran through a quick account of what Cheryl did not have. A short list of morbid and scary illnesses most people have heard of was easy for Ben to understand. After hearing that she didn't have these nightmares (brain tumor, bleeding, meningitis, multiple sclerosis, etc.), that what she had was most likely a drug toxic state which would pass and which could be suppressed, Ben was a different man. He was relieved and expressed trust in what I was doing. I turned her care over to the admitting doctor and went home to shower, debrief, detoxify with a glass of Chardonnay and my wife, but with inner wheels still spinning. Could I have done anything differently? How could I have managed my own bewilderment in such a way as to give the family more confidence that they were in good hands, even though mine were scratching my head?
What I would do the next time is, while 'standing there', trying to comprehend the situation, would be to address the entire situation, the needs of the husband as well, much sooner. Because I didn't know her diagnosis, I would have to depend on my clinical judgment of what her diagnosis wasn't. I might need to remind myself that if I haven't previously seen what I'm observing at the moment, it most likely is functional (a psychological cause) or toxic in nature, rather than imagining it might be some horrible threatening diagnosis I missed learning about in school. I can say this after my twenty five years of clinical experience. It would be much harder to have known this in my first few years out of training. There is simply no replacement for experience, particularly when encountering dramatic presentations as the only physician around, surviving by my own wits. The phone and references are available, but the sweat will run until some resolution is found. Success or failure rests solely on my shoulders. We do not get this type of experience in training. Some who stay at larger facilities may never get this experience. We have to be really alone to rise to some of the ultimate challenges in our professional evolution. There is nothing harder, and it is not for everyone in medicine. Success in this pursuit distinguishes the powerful clinician from the flock of lightweight generalists and clock punchers.
The exercise of this case also helped me to examine my own material about my credentials. I tend to understate the highlights of my own education for two reasons. The first is that I have found a poor correlation between a physician's credentials and clinical power or personal power. After all, it is orders of magnitude easier to accumulate impressive credentials than to become a superior clinician. The former comes from drive and compulsion, the latter from humble processing of life experience, intimate involvement with the 'human condition', and constant openness to self-examination. A sense of humor helps a lot. These paths are only taken by those who, by nature, must be this way. There is no choice. It is often a function of one's basic temperament. None of this is revealed on a CV (the "curriculum vitae", the list of schools and other training institutions attended with degrees attained). And so, the second reason I understate my own credentials is that I project out my own distrust of paper history, and do not want others to judge me based on this data alone. I realize that this is not only foolish in some situations, but works against my best interests. The fact is that almost everyone does depend on and trusts (foolishly or otherwise) credentials. Mine are adequate enough to help me to calm a situation of distrust and chaos.
Another salient feature to bear in mind is the popular list of frightening diagnoses that the general public has heard about through the media. I would address this list sooner than later. This upset husband stated that his wife was having convulsions. The lay person associates convulsions with life threatening conditions. As soon as I knew that Cheryl was not convulsing, I might have said to her husband, "when you first came in, you said that your wife was having convulsions all night. I want you to know that these are not convulsions. She is not having a stroke and does not have a brain tumor. Now, we'll be doing some tests to decide exactly what is going on here, but in the meantime, we will control these spasms with medicine and protect her from harm. She is not going to die. OK? Tell me whatever is on your mind. As soon as the tests come back, I will tell you what they show."
was admitted to the hospital and spent the rest of the day sleeping
with the help of the medicines that controlled her twitching. By the
next day she was normal, happy to go home and start dealing with life
without consuming dangerous drugs. I’m not sure who was relieved
more, Cheryl, her husband, or me.
All Rights Reserved © 2004 Jon Sterngold