February 29, 2024

Be Present

“Gende, we have a stroke alert coming to room two, ten-minute ETA,” the charge nurse called to me across the Emergency Department, thirty minutes before the end of my shift. It was a busy shift that day too, many patients with multiple medical problems- encephalopathy, respiratory failure and many of those cough/cold symptoms scattered throughout the day. But here it was, the last precious thirty minutes as I was struggling to finish everything in time, and we had an incoming stroke alert. I started to review the stroke alert process and contraindications for thrombolytics as I continued to work on my other patients.

EMS arrived and I took report at the bedside. I called my patient by name as I touched her shoulder. To my surprise, she looked brightly and swiftly toward my voice, demonstrating an alertness I had not expected. I did a very brief neurologic exam as we obtained a blood glucose and rolled her promptly to radiology for a head CT. As her images popped up, I saw a bright white circular area on the left, Okay, we’ve got a hemorrhagic stroke, I think to myself, it fits, she is on blood thinners, but as I was finishing my internal dialogue the pharmacist told me, “That white spot was on her prior CT, it’s an old calcification.”

Let us take a pause for the wonders of a highly effective and efficient team!  How amazing is it that our ED pharmacist is right there with me looking through the head CT and looking at prior images as well?!?!?!  We really show how great teamwork can be in the ED!  Way to go team! Thank you, we will now resume our regularly scheduled reading and sharing.

As I reviewed both old and new CT images, I agreed, no acute hemorrhage on my ED read. I heard the same in a phone call a few seconds later from the radiologist. We proceeded with activating tele stroke neurology for thrombolytic or interventional considerations. They beamed into the patient’s room and were assessing her via the video monitor as I walked toward the bedside. Usually, I avoid interrupting or distracting their assessment, however I wanted to watch their assessment, and I had not yet completed my thorough neurologic exam or got to really talk with my patient. They had just finished the physical assessment when I got to the bedside, and one of them was asking if I was present, how convenient for all of us!  We had a discussion over the monitor in front of the patient, they saw a hemorrhagic stroke, recommended reversal of the anticoagulation and controlled blood pressures, neurosurgery consult as well. I listened and took notes and wondered, are they seeing that calcification? I thought it was highly unlikely they would see that and make a plan of care without seeing prior scans or seeing the Radiologist’s read. They must have been talking about something I missed. Interestingly, after telling me their recommendations, they asked the patient, “what brought you here today?”

“Suicide,” she softly replied and closed her eyes tight as she started to cry. My mind came to a screeching halt. I again placed my hand on her shoulder. The consultants on the screen were discussing amongst themselves how a stroke in this area of the brain will cause psychiatric features. No follow-up, no change in plan, no further discussions. “Dr. Gende, you have Radiology on the phone,” came from the charge nurse at the patient’s door. I asked the nurse in the room to stay with and comfort the patient as I took the call. Upon finishing my phone call, I returned to the bedside. I called her by name and again introduced myself, “Did you try to kill yourself today?” I asked her gently. “Yes,” she tearfully replied. Between tears and pauses she shared how she took too many of her oxycodone pills trying to end her life. I added a toxicology workup, we placed her on ETCO2 monitoring and awaited acetaminophen results. After a chart review, her oxycodone was a combination medication with acetaminophen. As our labs resulted, she was found to have toxic acetaminophen levels and required n-acetyl cystine for management. Her opioid overdose did not result in any respiratory toxicity, so we continued to monitor and treat for the acetaminophen toxicity. I stayed late, as all of us would, to meet her son and with her permission, informed him of our workup and plan of care. Interestingly he seemed to have expected the news, he reported concerns as his mother spends most of her time alone despite many family visits throughout the day, her aging body has led to more depressed thoughts and less enjoyment of life. I offered my support and listened actively as I thought of my own parents and my in-laws. Loneliness can be so powerful it can drive us to suicide. I vowed I will do what I can to keep my loved ones from the despair of loneliness.

How many of us have taken care of the stroke alert that turned into an intentional overdose, an acetaminophen toxicity case? If you have, I know it came in the final minutes of your shift and I know it kept you there late doing what you needed to support your patient and their family. I desire to share with you my learning from this case, which has been modified and details intentionally left out for privacy purposes, was a few reminders.  First, listen to our patients. They tell us what happened, what is wrong, and what they need all the time. We usually just need to sit and listen, to be present fully with them as they allow us into their lives.  We are masters at working in a chaotic and persistently interrupting environment.  We need to hone those skills as we are present for our patients at the bedside. Second, we need to stay open to the possibilities of everything changing as we unveil new information and get to know our patients. As much as physicians are teachers, our patients give us some really great life lessons and lessons in medicine as well. It is our duty to stay open to learning both from medicine and from our patients. Finally, I was reminded to never blindly follow the consultants, the experts, the people we hold in high regard. Thankfully, I did not reverse any anticoagulation. I rediscussed the images with our Radiologist and after reviewing and reconsidering he stated again “no acute intracranial hemorrhage.” I called Neurology and let them know about the intentional overdose and my second discussion with Radiology, they agreed and appreciated the call and update as they signed off the case.

Stroke alert cancelled.

Alecia Gende, DO, CAQSM


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