The other day in the ER I had one of those patients whose family is so grateful, it puts you at a loss for words. The wife and son had brought in an elderly man, who had been in pretty good health until he was diagnosed with a dangerous cancer. Although the surgery had been done at the beginning of the year, he was still in the process of recovering. They had thought things were going well, and had in fact been travelling together to visit family in another city, when he began to show signs of a stroke: tilting off to one side as he walked, slurring his speech, not remembering what had just happened. Although much too late to make a difference if it was a stroke, they stopped the trip in our city and brought him in to the hospital.
(Public health announcements: 1) Jump out of burning buildings, don’t walk/run through them. 2) If you or a family member may be experiencing a stroke, go get it evaluated. We only have a window of three hours from the start of symptoms to be able to make a difference. Although 80-90% of stroke victims don’t qualify for the “clot-busting” drugs; but you might as well have a shot at it.)
Our ER prides itself on activating stroke alerts and moving quickly if there’s any question of the patient having a stroke and/or being in the time frame to benefit from emergent intervention. So the full court press that the family encountered – straight from triage into a room, ivs and labs, EKG, doctor (that’s me) evaluating them within minutes, CT on the spot – was only our standard protocol. Nevertheless, after hours of watching their loved one closely, becoming more and more frightened for him, and finally landing on the closest ER in despair, the wife and son were almost tearful with gratitude. I need to think of something more gracious to say than, “We’re just doing our job.” It’s true, but it’s not the whole truth. We were happy to have a chance to do our best for him.
He turned out to have a sodium somewhere down around 108. (Normal is ~140; you start getting neurological symptoms ~125.) For a few minutes I was afraid that the ER attending was going to demand from me a treatment plan for severe hyponatremia, seeing as how the ICUs were pressuring us not to admit anyone else for the night. At the moment, my thoughts on hyponatremia could be summarized as 1) bad; 2) dangerous; 3) fixing it has to do with normal saline and/or free water restriction; 4) bringing it up too fast is even worse, because it can induce central pontine myelinolysis, which is irreversible damage to the brainstem; and I didn’t want to be responsible for that. Fortunately, as news of the lab result circulated around the nurses’ station, the ER residents started quoting one of the attendings: “The treatment for severe hyponatremia in the ER is . . . admit to the MICU!” I heartily agreed; and for once, bed control was on board, and we got him out of there. (There is a formula for calculating how many milli-equivalents of sodium a patient is lacking, and a formula for arranging to replace that at a rate of 0.5 meq/hr; but it’s not inside my head.)