The following manuscript was submitted to the October 2017 Complications theme issue.

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Another night in the emergency department in Pittsburgh’s Northside: busy, loud and chaotic. Paramedics pulled patients on stretchers and nurses pushed patients in wheelchairs through the corridors. Of my patients, one in particular had me concerned. A woman named Amy with a past medical history of colon cancer was presenting with new-onset jaundice, dark, burning urine, yellow diarrhea, and nausea and vomiting over the past few days. Thin and tired, with saline running, she waited for a CT scan and labs that would likely contain bad news. It was a patient that you inherently knew would have “badness” on the CT, which would take some time considering the trauma patients that kept rolling in.

There was yelling in the hallway. Another set of paramedics, another patient. No rooms meant a spot in the hall. She was a young patient, hollering, talking back to the paramedics, clearly intoxicated in the hallway. The nurse taking report saw me and quickly grabbed my arm. “Please pick her up. She was found in a gym bathroom at a hotel intoxicated. I think she took something. She’s off her rocker.” I’m nearing the end of my shift. I sigh. “Okay. I’ll pick her up.” I’m tired, which isn’t fair to say considering Amy suffering from colon cancer, but I am.

I approach the patient, put on some gloves, and introduce myself. She’s 25, has an athletic build, gym gear, brown skin with her hair in a ponytail, and her name is Susannah. She grabs my name badge and smiles, “Doctor McL…Laren? McLaren? Are you a real doctor?” I smile and nod. “Oh.” She lays back and lets the badge go, rolling her eyes.

“I can’t feel my legs,” she says, then smiles again as she reaches down and touches her thighs. “There they are.” She’s breathing regularly with a rapid pulse in the 120s. She has large eyes with equal pupils that are reactive to light, and she’s overtly compliant with a neurological exam with a smile that stretches ear-to-ear: cranial nerve seven is very intact. A C-collar is in place without any signs of head trauma, and she giggles as I listen to her lungs, heart, and abdomen. She grabs her crotch and then her breasts and rubs them. “Am I naked? Can you see my vagina? Where am I?” she asks.

“You’re not naked,” I reassure her. “You tell me where we are. Tell me what happened today.”

She’s unsure where we are, but states her name and grabs her head saying she can’t remember taking anything today. She’s distressed now; frustrated that she can’t remember, then laughing to herself again. Per the EMS report, the patient stated, “I’m drunk. I had too many beers.” There was no paraphernalia, but I’m wondering if she’s taken something else: Ecstasy, K2, methamphetamine, or some other kind of stimulant while at the gym.

“Did you take anything today? Drink anything?” Her eyes are closed and she’s in the fetal position rocking back and forth.

“I don’t know. I’m drunk,” she says. No family or friends accompany her. There is no allergy or medication list, no past medical history or surgical history in our computer system per the nurse. Then she opens her eyes and sits up pointing, “Is that Ne-Yo?” she asks aloud as a young, black man is wheeled toward a room. Another patient in the hallway smiles at her and says, “God bless you, child” as the patient continues to squirm on the bed, grabbing herself again, yelling, “get this thing around my neck off! Now!” She curses and giggles again, her leg over the rail of the bed. I place it back on the stretcher. I look over and a gaggle of nurses are shaking their heads and smiling at me.

The nurse says, “I think she took ecstasy. They always act like this.” I agree. I present both of my new patients to my attending, who agrees with my plan to obtain lab work and scan Susannah’s head and neck considering she may have had a traumatic fall while in the restroom and is altered. We also agree that my other patient, Amy, needs a CT of the abdomen and pelvis to assess for any obstructive pathology associated with possible metastatic disease.

“That won’t be good,” my attending says after seeing Amy at the bedside. “She looks sick.”

I start catching up on tucking in my patients as my shift comes to an end, and the department swarms around me like a hive of bees, the buzzing of phones, the steady stream of conversation, scratchy voices coming over ground command walkie-talkies and the constant moving of bodies. Blurred white coats swoosh by as nurses carry pumps and bags of saline while clusters of surgeons with medical students in tow or internal medicine teams congregate outside of rooms of those being admitted or evaluated. The place is bulging; it seems too small for its occupants.

“Dr. McLaren, Radiology on 2915.” I reach for the phone, knowing full well that I’ll soon be giving Amy some very bad news: metastases to the pancreas with bile duct obstruction or something of that nature. “Dr. McLaren,” I say.

“Hey, this is radiology. You have the girl in hallway 21? Susannah? Yeah, this is a huge subarachnoid and it looks aneurysmal to me. I’d recommend a CTA for further evaluation of ruptured aneurysm.”

I want to say, “wait,” but I’m already clicking on the imaging studies in Susannah’s chart. My 25-year-old female has a massive subarachnoid bleed. There’s blood everywhere. What the hell is happening right now? “Dr. McLaren? How do you spell your last name?” And then I’m off the phone and at my attending’s side and we quickly change our plans. I find the charge nurse, “I need a resus bed now for the intox back south. She has a subarachnoid. Let’s put her in eight.” The charge nods and I quickly reassess my patient: airway stable, breathing and a strong pulse. I tell her nurse about the CT scan and her mouth is hanging open. “Let’s get her North now.”

I call neurosurgery, “I’ve got a 25-year-old female with an unknown past medical history found down in a restroom at the gym who presented as an intox with altered mental status who has an aneurysmal subarachnoid on CT. I’m getting a CTA of the head and neck now and bringing her to North 8. She’s tachycardic with a stable airway, alert but disoriented, we’re getting her on a monitor now.” He tells me that he has another head bleed in six that needs an external ventricular drain. “I’ll do them back-to-back,” he says.

We wheel the patient, and she’s still grabbing herself and cursing. She’s 25, I think to myself, I should have seen it before. The disinhibition. That’s why she’s acting so hypersexual, grabbing herself, cursing, yelling, her frontal lobes are covered in blood. We obtain further IV access, and on the monitor, she’s tachycardic to the 140s with a respiratory rate in the 40s and pressures in the 180s. She’s still alert and responding to stimuli; now she finally endorses a headache. We start a nicardipine drip and I ask for propofol and fentanyl to be drawn up. We cut off her clothes and place leads, oxygen, end-tidal CO2, and prep her for sedation with my airway supplies at the ready.

Neurosurgery is at the bedside. “I looked over her scan and she’ll need an EVD,” he says. “I’ll get my stuff, just make sure we have what we need to keep her sedated.”

I watch the monitor as we push the initial fentanyl. Now she’s spiking a fever. Neurosurgery shaves part of her head and I watch her long hair slide down into her lap. She’s prepped and then he’s cutting, first through skin then through bone. She moans and moves and we continue pushing doses of propofol and fentanyl, keeping a close eye on her airway, end-tidal CO2 and respiratory rate. I keep my hand on her chest, feeling every breath as the EVD is placed. He looks up and smiles, “She needed that.” We place soft restraints to prevent her from getting to the drain and the neurosurgery resident slips away to place another EVD in the next room. “What a night,” I think. And it’s not over.

It’s written on a piece of paper: a phone number and a name. Her mother. I call and hear the click, the static of movement and a small “Hello?” I introduce myself like a police officer on the steps of some suburban home at two in the morning with a dour look on his face and nothing but bad news. “Hi ma’am, my name is Daryl and I’m an emergency medicine resident physician at Allegheny General Hospital in Pittsburgh. I’m calling you about your daughter, Susannah.”

The tone changes immediately. I’m not a telemarketer or an unwanted solicitor or the next-door neighbor. I’m a stranger who knows intimate details about your child and those details will change your life, and mine. “Is she okay?”

I don’t remember this part as well as the rest of the case — it’s a bit of blur. I explain that her daughter is alive, but critically ill with a ‘bleed in her brain’ after being found down at a local gym and our initial thoughts about intoxication. “She doesn’t do drugs,” Susannah’s mother says exasperated, “She never has.” There’s also no known medical history to speak of that would account for the aneurysm.

She asks prognostic questions: What will happen? How will she do? Will she live? I respond to this as best I can with something that I believe fully: “She is in the emergency department being closely monitored by myself and the staff here. We’re doing everything we can for Susannah. Neurosurgery has already been consulted and successfully placed a drain to help alleviate the pressure in Susannah’s brain and they are an excellent physicians whom I trust.”

I listen to everything her mother has to say. I answer the same questions multiple times and will answer every question she has until she is satisfied that we are doing everything in our power to help her daughter survive. Then I call her father and start the process over. They’re both out of state and will have to make the drive in from out of town. “Drive safe,” I say at the end of another string of questions that any parent would ask. “She’s in good hands.”

She died a few days later in the operating room, not for a lack of trying. I would trust my life to the neurosurgery doctors who I consult on a daily basis and I know they did everything they could for Susannah.

On review, her urine drug screen was negative. A urine ethanol was less than 10.

Afterwards, I noticed that while driving around the Northside, a young woman with an athletic build would catch my eye, jogging along the sidewalk, her hair pulled up, long exercise pants on with a matching top and I would feel the same way I did when radiology initially called — a sinking feeling of being trapped and of being dead wrong. I noticed more and more women jogging and then I started to dream of Susannah. I couldn’t shake the feeling that I almost signed out a subarachnoid bleed secondary to an underlying aneurysm as a likely “Metabolize to Freedom.” I wish Susannah had been a simple case of intoxication like we had all allowed ourselves to believe. Susannah would be at home and I would not be up at night staring at the Pittsburgh skyline thinking about what else I could have done to change the outcome. I think of my own three year old daughter and the phone call I never want to receive.

In hindsight, I think of the many things this case taught me. One in particular is that in an emergent clinical setting, prove a diagnosis, even if it appears to be as simple as ethanol intoxication. Then pursue quick and rapid testing in a patient presenting with altered mental status to rule out easily addressable diagnoses up front and ensure rapid imaging modalities if concerned about the mechanism or history of the patient. In this case, it was clear from the start that being intoxicated at a gym is uncommon, and clearly a bystander’s input from the gym stating “she was working out and suddenly fell, clutched her head and stumbled to the restroom” would have changed the initial management from the outset. A solid history would have changed her triage via EMS and in the emergency department to a much more critical patient rather than an assumed intoxication with a dangerous ‘metabolize mindset.’

This may sound off topic, but if a patient is being funny, whether through jokes or gestures, ‘funny’ rarely makes us think of sick or critically ill. Unlike Amy, who was eventually diagnosed with metastatic disease from her colon cancer and appeared ill at the outset of her visit, Susannah’s presentation was dangerously deceptive. Since Susannah, I have experienced a handful of other patients deemed ‘intoxicated’ who prove themselves much more complex and concerning than initially thought. Since Susannah, I have made it a point to prove intoxication rather than assume it or allow it to climb up to number one on the differential without further critical thinking, and with this change in practice I find myself spending less time up at night worrying about my patients, my approach, and my practice.

Image credit: Grand River Hospital Emergency Entrance by Nick Matthews licensed under CC BY-SA 2.0.