Attack of the Zebras

An 80 year old mentor, and Physician once told me, “being a good doctor is not understanding the typical presentation of uncommon disease, but rather the atypical presentation of common disease.” I have tried to keep these words close as I have journeyed through Medicine…but it is difficult. We naturally want to gravitate, especially in Emergency Medicine towards the “Zebras,” or those disease states which we feel will cause the patients the most harm, (even though they may not be that likely): “Sir, you say you are having chest pain, and it feels just like your heart burn? Well it could be…but it also could be a heart attack, an aortic dissection, a pulmonary embolism etc...” We as Emergency Physicians are trained to think this way; we do not want to miss a disastrous diagnosis. We need to watch for the Zebras while herding the common cow. (Forgive me for the coarse analogy.)

Mikey was a 4 year old boy, who was born with a hypoplastic left heart, a severe seizure disorder, and was found to be confused and disoriented one recent afternoon by his mother. In the pediatric Emergency Room at Stanford, we are used to seeing sick children, with many underlying complex diseases. Mikey was no exception. The left side of his heart, which pumps oxygenated blood to the rest of the body, failed to fully develop. He needed a series of open heart surgeries to correct the problem. In addition, Mikey had recently developed epilepsy, or seizures, which he needed to take medication for.

When the paramedics brought Mikey into the Emergency Department he seemed very sleepy-he was unable to keep his eyes open, and the only noise he would make was an occasional whimper. He would respond to a loud voice or a slight shake, but then...out again. Although his heart rate, oxygen saturation, and blood pressure were normal, I was obviously very worried about him: this was a child with a complex medical history-could this be a cardiac problem, was it neurologic? Did he have a seizure? His mother assured us that his “heart was great, he just saw the Cardiologist 2 weeks ago, and had an echo-he was given a clean bill of health.” She also informed us that he had been taking his seizure medications, but “he is acting like he did after his last seizure.” I asked if anyone had witnessed a seizure…”no,” she replied, “I work at home and was in my office all day, but the Nanny was with him all day…she sticks to him like glue…”

“She sticks to him like glue…” I kept reiterating in my head. What was going on with Mikey? I was fairly reassured that this was not a primary Cardiac, or Pulmonary problem-his vital signs and physical exam just did not fit this picture. We ordered a chest x-ray, and EKG to be sure. He MUST have had a seizure-I wanted to get a CT of this child’s head, and to check his Dilantin level (the medicine he was on for his seizures)…I queried the mother again…”Do you know if he hit his head recently? “, “No,” she replied. “Has he been sick recently?” “No,” she replied. Any vomiting, diarrhea, history of diabetes, fevers…”No, no, no, no…” The Zebras, hoards of them, were doing laps inside my head….

A moment of clarity broke through the shadowy dust of the dancing Zebras…my attending, intrigued by the case, asked me if “the child could have taken, or ingested any medication.” That is a great thought I remember thinking…the mother’s response…”the Nanny is on him like glue…” We give him his Dalantin, all of the medication in the house is up on our pantry shelf, he cannot reach it.” She assured us that there was no ingestion of any toxic or illicit substances…”the Nanny…you know,” she replied. “Why don’t you just send off a urine toxicology screen my attending implored…you never know…this is our job to find things like this you know…” I agreed to send one, in the off chance we might stagger across something…but meanwhile, back to this child having a full blown neurological problem…I need to call the neurologist now!

“Get the child to the CT scanner as soon as possible, and I will be down to look at him,” the neurologist replied. Meanwhile, Mikey was still lethargic, he could not even hold his head up, or keep his eyes open. Intermittent whimpers and shaking reminded one of the abnormal trouble this small person was going through.

An hour passes…the CT of the head is normal, the Chest x-Ray is normal, his EKG looks great. His labs are all normal, including the dilantin level. His urine is clean, no sign of infection anywhere…meanwhile Mikey sleeps, no sign of waking, or really doing anything child-like soon. “He had a seizure, and is still very post ictal (or dazed from the seizure),” was the final conclusion of the Neurologist. “We see this all of the time, if these kids have a big enough seizure, they can be out for a while. There is also the chance that he is still seizing…” We agreed to watch him for another hour, if he was not awake, we agreed to admit the child for more intensive monitoring….

An hour passes. Still no change; the incessant hum of a busy Emergency Department getting louder, as more kids get checked in. I page the neurologist to inform her about Mikey’s lack of change, I grab another chart while I wait her call. Just then I see my Attending, smiling from ear to ear, “Sean, did you check Mikey’s Urine Toxicology Screen?” she asks with a mischievous grin….ohhh that thing, I forgot…

In one of the few Perry Mason moments of discovery in my career as an Emergency Medicine Resident, I look up the Tox Screen: Opiates-NEGATIVE; Amphetamines-NEGATIVE; THC (Marijuana)-POSITIVE….whoa…POSITIVE?? Just then the mother appears…”I KNOW WHAT HAPPENED, I KNOW WHAT HAPPENED, come here quick….” The events were playing out too quickly. I enter the room-“The Nanny” is there, as well as the father, and the mother is holding what looks like a bag of cookies? “Mikey was playing in his father’s car, and found these, he ate the whole bag: 100% hash cookies, keep out of reach of children!” “His father has bad back pain, he buys these in San Francisco.”

Mikey was stoned out of his gourde. He was alone in his father’s car for up to 2 hours eating pot cookies. The Nanny admitted to cleaning clothes and talking on the phone. Mikey was admitted, and eventually returned to earth almost 6 hours later! It is so easy to focus on the Zebras, or look for the common presentations of rare disease when you must first consider the cow, or the strange presentations to an ordinary sickness. Ingestions of any kind in children are not rare. I wanted Mikey to show me his stripes with the words “hypoplastic heart,” or “Epilepsy,” but a good doctor shouldn’t always be chasing zebras.

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Leap of Faith

“Oh my God!” I exclaimed to my wife as we neared the restaurant. A nice day out with the family, driving to lunch, abruptly changed by our gruesome discovery. Our route had been rather fortuitous: I missed one turn, made another wrong turn, got stuck in traffic, then finally we neared the restaurant. I looked over casually…and there he lay, completely by happenstance: Half on, half off of the sidewalk, a body contorted in a grotesque manner, coughing up blood, gasping for breath. I was completely caught off guard.

My wife Megan was shocked by the tone in my voice…"LOOK next to the car,” She saw him-speechless. I jumped out of the car and ran to his side. People on the street seemed oblivious to his existence. A lady on her cell phone, steps over the gnarled man, covered in blood, not missing a beat, no notion of compassion, talking, “Yea Sue, I’ll work out tonight…”

Who was he, where did he come from? Was he struck by a car…no one…myself, my wife and a stranger dying on the street. I yelled for someone to call an ambulance-no answer…my wife dialed 911. I called again...”HELP!!” I am used to dealing with crisis situations, yet suddenly I felt like an alien in a strange world. I had taken for granted the amount of help, the controlled environment we have in the Emergency Department. Patients like this come to us “packaged,” with a story. This poor soul was shattered, without a story, and was dying in front of us.

I stabilized his neck, I could feel a pulse. Finally a man on the street runs to us…”what should I do he asked?” “Let’s get him on the sidewalk!” We eased him onto level surface. He was coughing up blood, it covered my hands. He was looking right at me, through me, gasping for air. I realized part of his leg lay a few feet from his body. I held his jaw outward to ensure he maintained a secure airway. My wife screamed, “The medics are on the way!”

Someone yelled “His name is Joe…” “Who in the hell said that?” I thought. I heard the sirens in the distance. “Joe it’s going to be ok,” I kept saying to the man, knowing damn well it was not-I had to try to comfort him. I had the man hold Joe’s head as we tore off his clothes…his chest was filled with broken ribs, his legs shattered…a lady states clearly, but matter of factly-“HE FELL” I looked up, a lady smoking a cigarette on the 4th floor, curlers in her hair, points up to a balcony on the 5th floor-empty. A crowd had gathered to gawk like a strange freak-show carnival. The lack of emotion or empathy from anyone was indescribable, almost inhumane. His injuries suddenly made sense.

Joe still had a pulse. I knew the fall had severely damaged his lungs, his breathing was slowing, his pulse getting fainter, weaker. I kept telling him to hold on. He stopped breathing, his eyes were now lifeless. This was the longest minute of my life. I had nothing to help this man breathe. I was not comfortable administering mouth-to mouth given the amount of blood covering us. His pulse then stopped…the Engine Company arrived.

Described as a “Traumatic Arrest”, or loss of pulses and breathing due to a significant traumatic injury, I knew this man had less than a 5% chance of survival…do we TRY to save him? These thoughts raced through my head as the fire engine rolled to a stop. He JUST loss his pulses not 30 seconds ago I thought to myself. “I’m an Emergency Medicine Resident at Stanford, he fell from the 5th floor, we just lost his pulse.” In Emergency Medicine, no matter how complicated the patient, it always helps me to take a step back, and remember the “ABC’s”: Airway, Breathing, and Circulation…right now we had none of them.

The firefighters administered oxygen and started forcing air into his lungs with a mask. Another started CPR and attempted to start an IV. The Paramedics arrived. I now was also in unfamiliar territory…I did not want to “step on anyone’s toes”, this environment is the Paramedics territory, I needed to take a “back seat,” and let them run the show. Luckily I knew one of the Paramedics from the ER. He prepared to intubate Joe, or place a tube through his vocal cords, and into his trachea, to secure his airway. “Sean, I cannot see a thing,” he stated as he struggled to place the tube, “do you want to give it a shot?” I suctioned his mouth, and took a look: there was still a lot of blood, but we were able to pass the tube into his lungs.

This experience was truly eye-opening, and raised many salient lessons and questions for me: Why was I so under prepared to aid in an emergency like this in the field? Had we done the right thing for this man? Did I do the right thing as a Physician? Why did Joe die alone?

I was vastly underprepared as a physician in the field to deal with an emergency like this. My cars are now stocked with at least gloves, and first aid kits. Even though his injuries proved to be fatal, I feel we gave him every chance to live. After talking with several of my attendings, I think I handled the situation correctly: Joe’s care was under the direction of the Palo Alto Fire Department. They ran the call perfectly and renewed my respect for what they do day after day for all of us. (Physicians and lay people are covered under “Good Samaritan” Laws in instances like this.) Lastly, I often think of Joe. I like to think my wife and I stumbled upon him to be able to comfort him in his last moments...he really was alone on the street. I do not think we will ever know the events surrounding his death. As the ambulance left for Stanford, a lady commented to me, “That was really great what you did for that man…” “That’s what we do for a living,” I replied. That felt pretty good.

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