Tuesday, October 23, 2007

The Doctor is In

I went through my old e’s and found that I have almost 20 of these case studies. So I have some catch up to do. I sure hope none of my patients died in the interim. That would be bad. I think.

Today we have, “Altered Mental Status in a Homeless Man.” Let’s start, as we always do, with the photographic evidence.

This here thing-a-ma-bob with the squiggly lines is called an “electrocardiogram.” It’s called that because of a little known story. It's a good story. Let me tell it to you.

It seems that a clerk in a Western Union office in Cheyenne, Wyoming, in or about 1884, was sending a telegraph message.

. .- - | -- .
.. | .- -- | ... . .-. .. --- ..- ...
. .- - | -- .

(If you're out of pratice with Morse Code - you have to do one line at a time.)

A bandit rushed! He was a particularly cruel bandit with yellow teeth and small feet. He told the clerk to give him all the money – he said, “Give me all the money!” The clerk said he didn’t have any money, except the few bits people paid for telegrams to be sent. “Well then,” said the bandit, “send one of them there electric telegrams and tell somebody to bring money here! Now!” The clerk agreed:

--. --- - | ... --- -- . | .-- .... .- -.-. -.- | .--- --- -... | .... . .-. .
... -- . .-.. .-.. ... | .-.. .. -.- . | .... --- .-. ... . | -.-. ..- --
-.-. --- .-- .--. --- -.- . | .. ... | .- | ...- . .-. -... | - --- | - .... .. ... | --. ..- -.—
... . -. -.. | - .... . | ... .... . .-. .. ..-. ..-. | --..-- | | .--. .-.. . .- ... .
- .... .. ... | --. ..- -.-- | -- .- -.- . ... | -- -.-- | .- ... ... | - .-- .. - -.-. .... | ..--.. | | | .... ..- .-. .-. -.-- | ..--.. |

“You be typing a lot, little man,” said the bandit.

“I am telling them to bring a lot of money. That takes extra words,” said the clerk.

“Oh,” said the bandit.

Soon the sheriff could be seen in the distance with his posse and the bandit knew he had been duped.

“Why, I oughta send YOU as a telegram!” he spit through his cracked lips with breath that smelled like he had sex with his horse in lieu of breakfast.

Then the bad bandit smiled a terrible smile. He tied the clerk to his chair – arms, legs, and neck – and gagged him with a dirty oil rag. He took out his Bowie knife and CUT the clerk’s shirt open with a flourish. He did a pirouette and clasped his hands together as his pants got tight across the middle section. He paused for a moment. His eyes glossed over. He looked at the clerk intently. "You married? Involved?" Drool leaked out of his mouth.

With a snap of his head, his eyes cleared. “You got a needle and thread?” he asked the clerk. The clerk nodded towards the cabinet on the far side of the wall. “Thanks,” said the bandit.

The bandit rummaged through the cabinet and found what he needed. He went to the desk, took the telegram button thingey that you hit to make that tap-tap-tap sound, and then sat in front of the clerk.

“This is gonna hurt. Sorry,” said the bandit. He threaded his needle. The clerk’s eye was wide open (he lost the other in a terrible accident that the family refers to simply as, “The Baking Soda Incident,” then they all lower there heads and they shift uncomfortably in their seats). With the swiftness of a mule on crack chasing the candy delivery cart, the bandit disconnected the wires from the telegram button thingey, tied them a few inches apart on the thread, made an incision with his Bowie knife just below the clerk’s rib cage, and reached up in there with the needle in hand.

He sewed the wires to the clerk’s beating heart in mere seconds, then used a blanket stitch to close the wound.

“Now, I want you stay in this chair for a few days. Drink lots of fluids, and come see me if it isn’t healing properly, OK?” said the bandit.

With his eye as round as a dollar coin and face as pale as a bucket of chalk dust, the clerk, through his gagged mouth said, “Hhm-uh.”

The bandit stood still, tilted his head, and listened intently. “Can you hear it? Can you?” he said.

“Hrmph vtoph,” the clerk seemed to say.

“You. You’re an electrical-heart-telegram! I made a fun—”

Before the bandit could finish his sentence, ”Zing” came a .50 caliber slug into the back of his head. The sheriff had saved the day! Unfortunately, the posse opened fire at the same time, and the clerk took no less than three pounds of lead from his belt up.

A little over 50 miles away in Laramie, Wyoming, a clerk was hunched over his desk. He was transcribing the dots and dashes he was receiving from Cheyenne.

“What the fuck is that?” his boss said over his shoulder.

“Can’t make sense of it, sir. Sometimes I think it says … wait … it just stopped.”

“Must’ve been rats chewing the line. Throw it away.”

“Yes, sir.”

The story spread to the universities on the east coast. Collectively, they thought it was rather amusing, but may also hold scientific value. So they got some government money and perfected the technique on prisoners.

The name of the procedure was changed to reflect the Latin base more illustrative of the seriousness with which they viewed themselves – electro-cardio-gram, or “ECG,” for short.

OK. Where was I? Oh, yeah, this guy’s ECG:

Notice how the lines kinda go up, and then down, with flat spots in between. Might be important. Note, “Lots of flat spots on the telegram thingey.”

See those little rises? Those are called “P waves.” You can calculate the Atrial rate from the distance between them. Them big spikes are called “R waves,” and have something to do with Ventricular rate. I have no skills with which to apply such knowledge, but I am pretty sure it has something to do with his heart.

Note, “Patient has a heart.”

OK, enough with the pictures. Let’s go interview the guy!

BACKGROUND. A 38-year-old man is brought by ambulance to the emergency department. The patient was found lying near the stoop of an apartment building (he was asleep? Why are you bothering the dude? Let him relax?). The paramedics were unable to obtain any history from the patient en route because the patient has an altered mental status (maybe because his “altered mental status” was REM sleep?!?).

On arrival, the patient’s vital signs are an oral temperature of 95.72°F (35.4°C) (a little cool), a blood pressure of 88/40 mm Hg (relaxed), a heart rate of 38 bpm (very relaxed), and a respiratory rate of 24 breaths/min (deep sleep, ok?). His oxygen saturation could not be obtained. The patient appears to be a homeless, disheveled man and looks older than his chronologic age, with a faint smell of alcohol on his breath (so he had a beers, found a nice doorway, and went to sleep. You people running low on patients or high on residents? Can’t you just let the poor man sleep?). He can be aroused but does not follow simple commands (neither do you, numbnuts, until your first cup of coffee. Did you give him a cup of coffee?). He has intact gag and corneal reflexes (“gag reflexes” WTF did you people do? You crammed something down his throat, he gags, you write “normal” on the chart? WTF?). His pupils are equal and reactive to light. No obvious signs of head trauma are noted, and the examination of his oropharynx is unremarkable (so … nothing wrong with the guy? I reiterate – why did you drag his ass in here? He was sleeping!!). The results of his cardiac examination are significant for marked bradycardia (smoker, lived outside – got a problem with that?). A lung examination reveals rhonchi in the right lower lung field. The patient’s skin is cold, and his blood glucose level is 104 mg/dL.

An electrocardiogram (ECG) was performed before the physical examination (see Image).

What is the diagnosis and treatment? (Drunk, asleep, no coffee.)

HINT. The patient’s rectal temperature is 87.7°F (31°C). (Here we go with the rectal again. You drag this guy out of bed, cram something down his throat to make him gag, and now you stick something up his ass to check his temperature?!? What is wrong with you people?!? But, hey, we have something here. Several degrees lower. Think, Dr. Clyde, think. Seems familiar. Think. New Hampshire. Snow bank. 1981. Drunk. I GOT IT! He has “Cold Ass.” Used to get it all the time when I got drunk and slept in doorways. What’s the problem here? Just give him a cup of coffee and maybe a hot shower.)

ANSWER. Hypothermia secondary to alcohol use and environmental exposure: The patient’s ECG demonstrates the classic abnormalities associated with hypothermia, the most evident being profound sinus bradycardia. … (We’re done here. Cold Ass. Drunk and asleep. Move on.)

(Only because I like you people, I’ll leave the rest of the text intact. Remember – Cold Ass.). In addition, all leads show classic Osborn waves (J waves seen at the junction of the QRS complex and the ST segment). As always, the ECG must be interpreted within the clinical context; in this case, the apparent elevations of the ST segment should not be misinterpreted as evidence of myocardial injury. Other common ECG findings associated with hypothermia that are not seen on this tracing include atrial and ventricular dysrhythmias, as well as prolongation of the PR, QRS, and QT intervals.

This case features the most common etiology of hypothermia (ie, environmental exposure or accidental hypothermia). Other conditions often coexist, such as infection, metabolic abnormalities (eg, hypoglycemia), drug or alcohol overdose, and endocrine problems (eg, hypothyroidism); on occasion, any one or a combination of these conditions may also be the etiology.

In general, the life-threatening cardiovascular complications of hypothermia are cardiogenic shock and malignant dysrhythmias. Typically, rewarming the patient is sufficient to restore normal myocardial contractility and cardiac rhythm. For patients in shock who do not respond to resuscitation with warmed intravenous fluid and other passive and active rewarming techniques, low-dose dopamine is the recommended agent because of its inotropic and peripheral vasoconstrictive effects. Atrial dysrhythmias are generally associated with a slow ventricular response; therefore, treatment with digoxin or calcium channel blockers is not warranted. Bretylium has long been recommended for the treatment and prevention of ventricular dysrhythmias, though little evidence supports this practice. The use of amiodarone has increased in recent years as a result of shortages in the world supply of bretylium. For refractory bradydysrhythmia, external noninvasive pacing is recommended in favor of transvenous pacing because insertion of pacing wires into a hypothermic ventricle can potentially cause a fatal dysrhythmia.

Hypothermia is often diagnosed before an ECG is performed; however, the ECG can provide important clues to the diagnosis and yields critical information regarding the overall severity of the patient’s condition, from an electrophysiologic standpoint.

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