From the start it became obvious that this wouldn't be just another night float shift. I rolled myself out of bed around 6PM and noticed I had left my car headlights on. "You're fucking retarded!" I said to myself as a passerby smiled. The engine wouldn't start, so I went through everyone in my phonebook to try to get a ride to work... And no one picked up. For a brief moment in time I felt very alone and helpless. Then my next door neighbor, who is a UNC grad student, conveniently was driving back to campus for a late night studying session, so I was able to catch a ride and made it to work on time.
The night started with my attending calling me with 2 outside hospital transfers who were stroke patients coming to UNC around midnight. Thanks. Then the day resident informed me of one I needed to see in the ED.
This was a 23 year old law student who had tried to kill herself by overdosing on Ambien. When she awoke she noticed that she had pretty bad wrist drop, but that it was improving. She couldn't extend her wrist or her fingers on her left hand. I obtained the history and physical exam, and informed the patient that she likely had a radial nerve palsy (Saturday night palsy) from compression of the nerve in the spiral groove of her humerus when she was passed out from the Ambien. I told her that I was optimistic that her wrist drop would improve on its own with minimal intervention. She seemed pleased with this explaination. I would have liked to inquire why a young, attractive, 23 year old law student with her whole life ahead of her would try to kill herself, but I figured that this wasn't my role, and the psychiatrists were better trained for this. Besides, I just got paged that the 2 outside hospital transfer patients had arrived so I had to keep moving.
Next I went to the ICU to see a 60 year old patient with atrial fibrillation who developed acute onset left sided weakness and slurred speech. He was given tPA (a potent thrombolytic clot busting drug) at the outside hospital approximately 2.5 hours after his symptoms started. His family was bedside and were hopeful because his mental status and speech were improving. Complicating the picture was his fever and right middle lobe infiltrate on chest x-ray; he had developed an aspiration pneumonia like so many of the other stroke patients I see. His heart rate was also climbing in to the 120s, and his large family was nervously glued to his heart monitor. I wouldn't hear anything else from this patient for the rest of the night. He told his wife that she was a worry wart and that he would be fine in his slurred/dysarthric tone. He had known about his atrial fibrillation for many years, but chose to ignore it. I wish he didn't. His nurse must have pushed the labetalol for his heart rate several times. As days progressed, the patient's aspiration pneumonia worsened, and he became septic. He required intubation and stronger antibiotics. He currently remains in the ICU.
The next patient I saw arrived to a floor bed. He was a 60 year old with laryngeal cancer who had an emergent tracheostomy placed several years prior. 3 days ago he had a bad headache, nausea, and vomitting. He went to an outside hospital where a head CT was performed which was normal, so he was reassured and sent home. His symptoms worsened, and he sufferred multiple falls. He returned to the outside hospital where an MRI brain was obtained which showed he had a stroke involving virtually his entire cerebellum. His fourth ventricle was narrowed with two dire consequences: 1) his ventral brainstem was compressed giving him hemiplegia, 2) cerebral spinal fluid flow was restricted causing elevated intracranial pressure. This would kill him if it wasn't addressed soon. Neurosurgery was called immediately and they took the patient to the OR for a posterior fossa decompression.
While I was dealing with this devastating cerebellar stroke, a confused medicine ICU resident called me asking why a stroke patient who received tPA was admitted to the medince ICU instead of the neuro ICU. We made arrangements for the patient to be transferred to the neuro ICU. This was a 79 year old man with coronary artery disease, atrial fibrillation, and a prior right middle cerebral artery stroke 1 month ago who also developed acute onset of left sided weakness and slurred speech. His systolic blood pressure at the outside hospital was well over 200 mmHg. He had just received thrombolytic therapy 1 month ago. An outside physician decided to administer 80 units of lovenox (a type of heparin/blood thinner), and then give thrombolytic therapy on top of this with tPA. I read the transfer summary in disbelief, shaking my head. The patient had a stroke a month ago, had dangerously elevated blood pressure, and was given a moderate dose of heparin; all contraindications to receive further thrombolytic therapy with tPA. The next day the patiend developed hemorrhagic transformation of his stroke, had herniation of his brain, and died. For him to go quickly was possibly the best outcome. His wife was tearful, as she had hoped to celebrate their 60th wedding anniversary the next month.
The last patient I would see that night was a 61 year old female with diabetes and also reporedly a prior left brainstem stroke. She reported feeling fatigued, and 3 days prior she developed a headache and nausea. She noticed this while she was sitting in church, and reported she couldn't make it back to her car because of weakness. Her voice had become hoarse, and she had problems with walking, falling over to her left. My first concern was a cerebellar stroke, however I reviewed her brain MRI and there was no evidence of an acute stroke. Her prior brainstem stroke was not really visible either making me question this history. She did have a narrowed left vertebral artery which supplies blood to the cerebellum, however this can actually be normal. The radiologist posted his report on the brain MRI and I agreed with it. The patient would go on to list her 20 home medications with multiple herbal supplements, and then she reported a long list of allergies, including metacresol, a preservative in insulin. She did have some odd physical exam findings though. Her voice was hoarse, she had decreased sensation to pinprick and temperature of her left face, and she had decreased sensation to light touch of her right body which she said was old from her prior stroke, and she fell to her left when she tried to walk. Everything in the history and exam pointed to stroke, except the MRI was essentially normal. I told the patient that I didn't know what was wrong with her, but that she probably didn't have a stroke. She had bamboozled me with her long medlist and allergies, so I figured that whatever she had probably was primarily a psychologic disorder. She may have been having a reaction to stress in her life making it difficult for her to walk. I told the ER resident what my thoughts were, and she agreed with me. It turns out everyone was wrong.
The next morning after presenting my patients on rounds, I walked 2 miles home as my car battery was still dead. While I was fast asleep, my co-resident was reviewing the brain MRI from the previous patient. He called the radiology resident about a bright spot he saw in the back part of the patient's brainstem. It turns out that there was clearly a stroke in the dorsal-lateral medulla. The patient had Wallenburg Syndrome, a very well known phenomenon causing loss of sensation to temperature and pain on one side of the face, loss of sensation to light touch to the other side of the body, unsteady gait, and on occasion, hoarse voice. She had Wallenburg Syndrome, and I had missed it, as had the ED resident, and the overnight radiology resident. I quickly sent an e-mail to my attending and coresident apologizing for my error, and thanking them for double checking the MRI. The next day I apologized to the patient. This was well received.
That error weighed on me for awhile. It made me question who's really crazy and who is sick. I'll never forget this night of four strokes. Eventualy AAA would come and give my car battery a jump start, and I made my way through 8 more crazy night float shifts.
