Just Not Right

They say that you need about 10,000 reps of anything to be an 'expert'. Average US residents in EM, then, graduate slightly less than that; even assuming we are rockstars, 3-4 years of training, up to 2000 hours a year, 2.0 patients per hour--which would be crazy busy--we only see, at best, 8,000 patients. Thus, a learning curve still exists.

I had a neurology attending describe partial status epilepticus my second year of residency by standing at the foot of the bed and staring at the patient. She almost seemed to test the air for a whiff of the electrical storm in the patient's cranium. Seemed like an eternity; no exam, just observation. Finally, she said, 'yep. Seizing'. I scoffed, internally, of course. But the EEG, as the greyhairs and nohairs reading the post have already surmised, was positive. She later explained that you eventually just get a feel for who is seizing or not, and that her decision is primarily made when she walks into a room based on her gestalt. Malcolm Gladwell talks about this phenomenon as 'thin-slicing', the contribution of our automatic intelligence. In EM, it's as big a part of our job as any other, and usually represents the sick/not sick decision point, but it's developed only over time.

I've had two cases recently where my 'thin-slice' impression was the right one. In the first one, a 74 yo M presented by ambulance with altered mental status; per EMS, he had a witnessed syncopal episode in the yard while drinking with seizure-like activity and persistent altered mental status, minimal trauma from the fall, and no other associated symptoms. Normal pre-hospital sugar. The paramedics stated, 'he has a history of seizures' as well as alcohol problems. Actually, they said, 'pt has a history of seizures and is post-ictal, and he was drunk too'. Hmmmm. Perhaps; a lot to unpack there. If he's post-ictal, that doesn't help me; prolonged post-ictal states can be a sign of status epilepticus, or a representation that it wasn't a seizure at all.

His exam was odd; his GCS was about 12 with confused speech, eye opening to voice, and localization, but he seemed to favor his right side. Sugar was again normal and a focused airway exam revealed an intact gag. I watched him for about 15 minutes, and he improved, consistent with a post-ictal state, so was sent for CT.

Of course, it was no post-ictal state, but a spontaneous ICH. He declined again and was intubated. In retrospect, though, this was not a surprise; at the foot of the bed he already didn't 'smell' post-ictal. Think of how many post-seizure patients we see; this is a very typical patient, usually a brief or non-existent work-up, maybe a load of AED, and discharge. But the persistent altered patient...time to think a bit more. You can use the AEIOU TIPS pneumonic, standing for alcohol, endocrine causes (hypoglycemia), infection, opiates, uremia, trauma, intracranial causes, poisoning, or stroke; but the pneumonic can represent a trap of sorts. Some require more prioritization than others and vastly different treatments. Unless you give IV dextrose, narcan, ceftriaxone, and charcoal via NG after LP and intubation to every altered patient, more work is needed to get to the bottom of it. Start with the sick/not sick question; if you think they're sick in your gut, get to the bottom of it.

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Frequent Flyer

As he's moved over to the stretcher, he complains of chest pain 'just like his past MI'. Sweet! Admit! says my inside voice. To be perfectly honest, at 3 in the morning, the rest of the history is window dressing. Hypertensive. Then he adds on. On dialysis, missed the last 'couple'. And he fell down nine stairs, with a bump on the head. And he's on coumadin due to a prior PE.

I was already done, now I'm even more so; when I go to his chart to look at his history, though, the true story emerges. Every four days, he has a discharge summary; each one essentially the same. Came to ED, needed dialysis, admitted, dialyzed, sent home.

These are the people that are eventually easier to just buy an apartment and a social worker for. Each of these visits gets billed out, each time labs are drawn, IV meds given. Reminds me of someone getting their liver eaten and then pushing a rock up a hill...