| I was on night float this past week. What that means is that from the hours of 8:00 PM until 7:30 AM, I was the only neurologist in-house covering the entire hospital. My responsibilities included: 1) covering all the patients on the inpatient neurology service; 2) taking any neurology consult from the ED; 3) taking any neurology consult from the hospital. All things considered, it wasn't too bad; I was able to catch at least a couple hours of sleep each night (or as the gal pal put it, "this might be the only time where you're allowed to sleep on the job!"). But even though it was just a week, I managed to come away with quite a few good stories. Hallucinations
There was a patient who had been admitted prior to the start of my shift with a pretty significant hemorrhage in her brain. Given how big the bleed was, it was pretty surprising that she was actually fairly stable. However, in the middle of the night, she began to have some vivid hallucinations, first about a jaguar prowling her room, andthen about some creepy man in her bathroom, staring at her and repeatly saying, "I'm just looking. I'm just looking." I went in the examine her and also to try to assuage her concerns. Hallucinations aside, she was fine (we even checked a repeat head CT just to make sure). However, my attempt to convince her that none of her hallucinations were real was an exercise in futility. In fact, after I left her room, she began to hallucinate that I was in her bathroom. (Hey, when you gotta go, you gotta go!) When the neurology wards team went to see her on rounds, she told the team about how "Dr. Wang" had been hanging out in her bathroom all night long, tormenting her the entire night. The best part about this story is that she also claimed that I was part of this big conspiracy to maker her look "crazy" because I was running all these tests on her. What can I say, I'm a bad, bad man. Running a Rapid Response
In our hospital, a Code Blue gets called whenever a patient becomes unresponsive, isn't breathing, and has no pulse; it's the real-life equivalent to those medical TV show "emergencies" where people are performing CPR incorrectly (way too slow of a pace on the chest compressions), busting out the defibrillator paddles when the patient is in asystole (which is NOT a shockable rhythm) and melodramatically yelling "CLEAR!" every 2 seconds. A "Rapid Response" is sort of the lite version of a Code Blue - that is, a patient might be heading in the wrong direction, but isn't quite there just yet. On one particular night, I was woken up by a page from the nurse saying that one of our neurology wards patients was having a seizure. As I groggily walked down the hallway towards her room to go assess her, the code bells went off and the operator announced a Rapid Response in that patient's room. Walking into her room, I could see that she was in the midst of a seizure (which in and of itself isn't that big of a deal). However, the nurses were concerned because her oxygen saturations had briefly dipped to 70% (a very valid concern) before coming back up. As I stood over the patient's bed, monitoring the patient's seizure, glancing at her vital signs, and watching the nurses attempt to hold her down, I could feel the gears in my head slowly start to work. Ever so slowly. You know how when you turn on your computer, it takes a while for the system to boot up? That's what it felt like with my brain at that very moment. I was awake, and I was aware of everything that was going on, but I just couldn't quite process it all. At last, after what felt like an eternity (but was probably more like 30 seconds), Windows Vista my brain finally came online. "Let's give her some ativan," I said to one of the nurses. About a minute after she received the medication, her seizure stopped. I found out the following day that all her seizures were actually non-epileptic seizures (AKA "pseudo-seizures"), which I had sort of suspected to be the case anyway. Still, I guess I technically ran my first "Rapid Response" that night. I Can Math Good Too
Speaking of seizures, there was another night when I got a consult from one of the surgery residents regarding one of his patients. "This lady's been doing this weird head twitching thing," he explained, "I think it might just be tardive dyskinesia from the risperdal she's been taking, but I just want to make sure we're not dealing with a seizure or something." I immediately went over to the ICU to assess her. Even from the door of her room, I could see the rhythmic jerks in her head to the right and the eye "twitches" causing her eyes to deviate to the left. This was NOT tardive dyskinesia. "How long has she been doing this?" I asked a nurse. I was told this had started at 9:00 PM. It was midnight now. It had been going on for three frickin' hours before someone thought to call the neurologist. "Okay, she might be in status epilepticus (prolonged seizure activity that won't stop on its own). Can we please give her 2 mg of ativan and load her with some fosphenytoin 20 mg/kg before she fries her brains out?" I shouted to the surgical resident. After discussing the case with my attending and coming up with a game plan, I touched base with the surgical resident again: "So we're clear on the plan? Load with fosphenytoin 20 mg/kg. if she's still seizing 30 minutes after the load, you can either load with phenobarbital 20 mg/kg or induce a pentobarbital coma. Give me a call if you have ANY questions." I was very, very specific about the dosing of the meds, and it certainly seemed like he understood. I checked back on the patient an hour later, and she was still twiching away, so I instructed the surgery resident to try the phenobarbital load. "20 mg/kg," I reminded him of the dosing. I got tied up later on and didn't have another chance to see the patient, but since I didn't hear back from the surgery resident the rest of the night, I assumed our plan had worked. The following night, out of curiousity, I checked on the follow-up neurology consult note from during the day. Turns out that the patient had only been loaded with 120 mg of fosphenytoin, or 10% of what the proper loading dose was supposed to be. And lest we all think that perhaps the surgical resident simply made a typographical error and neglected to add in an extra "0," he did the same thing with the phenobarbital load also - 120 mg total. Even now, I'm a little infuriated at how the whole situation was handled. I don't really expect a surgeon to necessarily know what a seizure looks like, but I assumed that at the very least, he could do math. I guess even that's asking for too much. But in fairness, I suppose I should give him a little credit. At least his patient didn't accuse him of hiding out in her bathroom, staring at her and saying, "I'm just looking. I'm just looking." |
