The day started out quite well. At 6:45 AM, my friend Norman and I were able to start and eventually complete a 40 mile bike ride. We did 'loops', the 'on call' routine, which entails riding the same roads over and over again, never more than 10 to 15 minutes from home. This is the only way to ride while on call. I cannot overstate how important it is to do a ride, especially on the 'on call' days. A good ride will reliably jack up the endorphin blood level, an absolute necessity, before the inevitable poop hits the fan. It went well, though somewhat easier than usual, as I was still a little over trained from the Girona trip, and Norman was recovering from a recent injury. When the calls started coming from the Emergency Room, I took a quick shower and headed downtown.
I drove to the hospital listening to Radiohead's The Bends on my new and awesome sound system. The last song I heard was Sometimes You Sulk, Sometimes You Burn, which, in retrospect, portended future problems. I made my rounds at a comfortable pace, visiting patients seen by me or my partners during the previous week, with a small number of routine type new consults. Nothing at all stressful. At about 6:00 PM I was wrapping it up and thinking about the 7:30 PM French movie at the down town art house. Just as the endorphins were breaking down and leaving me a bit vulnerable, like Sampson without his hair, I picked up a tough case on the floor. As my input to this case was unfolding the ER started to call. Suddenly I had three patients with diverse and serious problems.
On the floor, the case was a 42 year old lady with a diagnosis of Multiple Sclerosis who, over the last week, had progressively declined from no problems walking to barely walking with the assistance of a large walker. She had a Neurologist in a neighboring town, but was not able to reach him, so she had gone to her local ER. Without a hitch, here she was, my problem. There are two ways to look at this. The first is to say "Wow, what a nice opportunity to help someone. I am so thankful she did not find her Doc." The other response, "Thanks a lot. I had enough to do already and now I am going to miss the movie." At first glance I assumed she was having an MS attack and the treatment is standard: continue the medicines that lessen the chance of an attack, and add large dose of steroids, which can be beneficial for an acute attack. I considered dismissing her, suggesting she see her hometown doc when available, who could continue this treatment plan.
However something about her problem did not make sense. The symptoms were typical of MS, in that the evolution of the problem was a matter of days and the location of the problem, per my examination, was the thoracic spinal cord, not at all unusual for an MS attack. A sudden onset would suggest a stroke and a more gradual onset would suggest a tumor. She was severely weak in both legs. The two, right and left, motor tracts in this part of the spinal cord are not contiguous. With this degree of weakness, an area of inflammation inside the spinal cord, which is the way a MS attack works, should have also caused some degree of sensory loss - numbness. On the other hand, some type of mass pushing on the spinal cord will frequently compromise the artery supplying blood to the cord. When this happens, the motor tracts are most vulnerable. In this latter setting, motor loss without sensation problems is common. I wanted to think about this some more, but then the ER called. After reflecting on this confusing array of symptoms, I fortunately decided not to send her home.
The first ER case was a very elderly lady who, while eating, suddenly dropped her fork from the right hand and was unable to speak. The ER doc felt it was a stroke on the left side of the brain. The patient made it to the hospital in time get the clot buster called TPA, but the doc was concerned about her age, and thought it might be too risky. In some patients, and the older the more likely, the TPA clot buster will cause a massive brain hemorrhage into the area of recent damage. His concern was appropriate, but there are no age limits for TPA. As long as the patient and/or family understood the risk, I was in favor of giving the clot buster. The patient had two very nice and intelligent daughters. I was able to go over all the pros and cons in record time. We called for the medicine from pharmacy and as a last precaution I went to the computer to view a CAT brain scan and lab work done on the patient. The scan looked OK, no bleeding into the brain and no hint of any other problem, such as a tumor.
However when reviewing her blood work, I discovered some of the lab results had not been completed. This never happens. The blood sent to the lab in this clinical situation of acute stroke, is labelled "STAT", and the results are always back in the chart by this time. For some reason this patient's blood work was mislabeled. When I called the lab to ask for the rest of the blood work, I was told it would take an additional 30 minutes to complete the coagulation profile and the chemistry profile which includes electrolytes (salt concentration primarily), kidney function analysis and blood sugar. Normally the coagulation studies are abnormal only if the patient is taking a prescribed blood thinner like coumadin, and the daughters were certain this was not the case. In the computer, I found a fairly recent normal blood chemistry analysis done on her. We did a quick finger stick for the blood sugar, which was OK. I then went over the conundrum with daughters. I told them the situation looked like a stroke which would likely improve with the clot buster if given immediately, and though we like to make sure all the labs are normal, there was no reason for these labs to be abnormal. Even if abnormal, it was unlikely a chemistry problem would mimic a stroke. I suggested not waiting and going ahead with the TPA. Were they OK with that? What could they say.
She received the usual 10% of the entire dose right away (bolus) and we were dripping in the remainder over an hour, which is all standard. I had asked the lab to call us when the labs were completed. In 5 minutes, (note: not 30 minutes), we learned the coags were OK. Ten minutes later we learned the sodium level was critically low. Low enough to cause neurological problems.Whoops. How this happened, I am still not sure. The question: did it drop because of the stroke? That is possible. Any brain injury can make your pituitary gland and neighboring hypothalamus area go on tilt, resulting in the "inappropriate" release of a hormone ADH (antidiuretic hormone). This hormone causes the kidneys to hold on to pure water to such an extent, the blood sodium level can be diluted to her critical level. This fast? Never.
Why does a low sodium cause neurological dysfunction? Most fluids, other than pure water, have a number of particles in solution. The number of particles determine the osmotic force. Small particles like sodium are in the bloodstream at a high number or concentration. There is a membrane between all tissues freely permeable to water but not to sodium or other particles. When the sodium concentration drops in the bloodstream, and the blood becomes contiguous with the brain cells, water is sucked out of the blood into the brain to maintain equal osmotic pressure on both side of this membrane. This is a well established simple rule of physics. The result is like a dry sponge absorbing water. Like the sponge, the brain cells swell and brain problems ensue. Usually the symptoms come on gradually. In this case the low sodium likely caused a small speech center seizure resulting in "speech arrest." This explains why her problem came on suddenly, mimicking a stroke. The brain in this area is then short-circuited by this seizure activity, and it takes a full day or so in some cases to reboot. This is the proverbial curve ball that always seems to come my way when least expected. She received a dangerous medicine, one that can cause a massive brain hemorrhage, for no reason.
So I had to drag my tail back into the room, announce the news to her daughters and turn off the TPA. They were not happy. The ironic part about this screw up was I could have easily remained silent about my blunder. It was likely she would fully regain her normal speech once her sodium was corrected. And in fact this did eventually occur. If she did not actually have a structurally damaged area, a stroke, the chance of hemorrhaging was minimal. Had we proceeded with the original plan to give a full dose of TPA, I would have likely been congratulated for such a good outcome.
My wife, the most enthusiastic of my many critics, would have chastised me for getting into this predicament.
" My husband," I have heard her tell her friends, "has a 'wait' disorder."
" He doesn't look too big or too thin," they might reply.
" I said 'wait,' not weight. "He can't."
Or, as she tells me, perhaps when going to the coast and I become very concerned we may have missed a turn,
" Why do you always drive me nuts by hitting the panic button?"
" I love that button," I reply.
Back to the MS patient. With some distance and time to think about it, I concluded she was not having an MS attack. Something else was going on. I cancelled my initial orders and set her up for an MRI the next morning through the appropriate area. It showed what appeared to be a metastasis of a malignant tumor, primary site unknown. Likely it was a lymphoma, because the scan also showed some tissue suggestive of this, outside of the neurological area. If dismissed, my initial plan, she would likely have been permanently paralyzed in a matter of a day or three. My friends, the Neurosurgeons, removed the tumor the following day and she greatly improved. We are awaiting reports to define the cancer from my other friends, the Pathologists.
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| This is a MRI side view of the patient's thoracic spine and spinal cord The spinal canal is behind (right) the vertebra.The parallel vertical white lines are normal spinal fluid on either side of the actual spinal cord. The arrow is pointing to the tumor, almost 2 vertebral body lengths, on the back side of the spinal cord, compressing the spinal cord to the extent the spinal fluid is obliterated |
The movie was over at this point which was irrelevant because it was back to the ER. This time it was a 50 year old guy of short stature, nicknamed ' Peewee," with "possible stroke." Less than an hour before arrival, he suddenly became wobbly and claimed he was seeing spots. His wife took his blood pressure, which was high, and called the 911 crew. He was quickly evaluated by the ER staff, this time with blood work, all in the chart, and nothing to prelude the TPA. His blood pressure was too high initially, but he was placed on intravenous meds bringing the BP to the 'safe' range for the TPA. He had a CAT brain scan showing no bleed but "early changes of CVA (stroke)," according to the radiology report.
When I arrived he was mildly confused, without visual complaint but wobbly when he sat up. During my examination, it was obvious his eyes were not focused on me when answering my questions.
"Peewee, can you see OK?" I asked.
"Yes," he quickly replied.
"How many fingers am I holding up?" (showing him my five fingers).
"One," he answered without hesitation.
"How many now?" (showing him two fingers).
"Five," he replied, again without hesitation.
His pupils were normal size and responded perfectly to a light by becoming smaller. This meant no major neurological problem with the eye nerves (optic nerves).
Peewee had "Anton's Syndrome," a rare problem occurring when someone has a sudden loss of function in the back part of the brain, the visual cortex, on both sides. Almost all cases are due to stroke. The victim will not realize the problem of ' cortical blindness,' as opposed to blindness from an eye disorder. With this syndrome, the patient is usually adamant he/she can see, and will confabulate when challenged.
So Peewee's condition looked like a stroke, and the CT was read as such. Not so fast on the TPA this time. Something about the stroke diagnosis was not right. Two blunders in one night are grounds for dismissal, or at least a beating with a cane. I suspected he had a condition with long name that occurs when someone's blood pressure goes up very high or not so high but very quickly changes. It's called "Posterior Reversible Encephalopathic Syndrome," aka PRES. The change on CT, read as stroke, was too early to likely be a stroke (changes on CAT don't occur until about 12 or more hours). Everything else was consistent with PRES. In this condition, fluid leaks out of the blood vessels in the back part of the brain, the visual cortex, but, mysteriously, no where else.
I decided not to order the TPA, but I needed some data to back this up. The first thing was to look in the back of his eye with my handy ophthalmoscope I always carry in my black bag. There are abnormalities specific for severe acute blood pressure problems one can usually see. This part of the examination is a somewhat difficult maneuver in an uncooperative patient. I always ask the cooperative patients in my office to fix their stare to something hanging on the wall opposite the exam table, (translate: write off all art work) which makes this much easier. Peewee, being blind and also confused, was going to be a problem.
So it was my face in his face for several minutes without success. Then I had to go to plan B. That is, make up plan B and go to it. I asked a medical student who was helping, to play a song on her cell phone and hold it in the exact location which would help me out, if Peewee looked at it. She played Sam Cooke's Cha Cha Cha. Again I tried to look in the back of his eye. Again Peewee proved uncooperative. Then I pulled out my phone, gave it to her to hold, and played Jay Z's Empire State of Mind. At first this did not work but when Alicia Keys came in with the chorus.
" New York. Concrete jungle where dreams are made of ...."
He went right to it. The woman's voice! I will remember that detail next time. I was able to see he did have most of the changes consistent with blood pressure problem. I don't think my butt was moving with the beat, though it was possible, since I was not paying any attention to that end of my body.
So he went to the ICU on appropriate IV meds for his blood pressure and no TPA. I was tired and hungry, so I headed home. The endorphins were a memory. I had ordered an MRI brain scan, confident it would show abnormalities confirming my opinion. The tech was still in the house and I calculated the scan would be ready for me to pull up on line to review, after the drive home and a snack. I called the nurse in the Neuro ICU from the car to make sure everything was in order. He told me that Peewee was now complaining of a headache and he had announced he was not having the MRI because he was claustrophobic. I made a U turn on the Interstate. I love that move. Back to the ICU, got to reason with Peewee.
"Peewee, I hate to kick you when you are down, but you are blind and you cannot be blind AND claustrophobic!"
" I'm not blind," he reminded me
"Ok, we will bring in a spare MRI machine that has a ten foot clearance in all directions."
"Maybe I can do that," he offered
Down to the scanner with Peewee, the nurse, a syringe of morphine and another with Versed (very short acting Valium like drug). In order to give these meds, hospital rules are: The doctor has to be in the MRI scan room. He did not bite on the big scanner story. An hour and a half later we had a snoring Peewee, two empty syringes, a hungrier doctor and a decent scan, confirming PRES.
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| This is an MRI brain slice though PeeWee's brain. The slice is parallel to the ground and you can see both eyeballs at the top (front of brain). The normal brain is grayish. The black is normal fluid inside the brain. Within the drawn rectangle, which encompasses most of the visual cortex, the bright white is the fluid which has leaked out of the blood vessels because of the very high blood pressure. This is not a stroke and in a day or two, with good control of his blood pressure, it was reabsorbed and he could see normally |
With a balance of being settled and unsettled, I finally made it to the car for the drive back home. I removed Radiohead for fear of hearing the lyric "..sometimes you burn," which could've adversely tilted the delicate balance. I looked through my music selections hoping to find an old friend . Someone my age or older. Someone who had weathered worse storms than me, and had poetically recounted them. It was 1:30 AM and if I had any hope of sleeping, I had to calm down.
Easy, Leonard Cohen's The Partisan. Three and a half minutes. I played it four times:
There were three of us this morning
I'm the only one this evening
I must go on
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