I went to see the next patient. The chief complaint read “18 year old student, intoxicated.” Great, I thought, this will be the 4th tonight, and possibly the 400th of my career. I approached the bedside and found a half-naked girl lying on the stretcher with her eyes closed. She had wiggled out of her gown and was trying to curl up under the still-folded, thinly woven cotton blanket. Her vital signs and finger-stick glucose were normal, and she had breathalyzed four times the legal limit. The assessment of an intoxicated patient from a physician point of view is fairly straightforward. First is an examination for any overt signs of trauma. Then, neurologic and mental status examinations are performed to detect abnormalities, perhaps indicating occult injury or illness. Of course, these examinations will often be problematic in someone grossly intoxicated. After enough years practicing emergency medicine, I have become comfortable with a certain amount of abnormality, while retaining a high level of sensitivity for abnormal abnormalities. I asked the nurse, Lisa, to help me to replace the young woman’s coverings. “I’m Doctor Hack. Can you tell me why you are here in the emergency department today?” She half opened her eyes as the nurse held her up and we struggled to redress her and she mumbled, “I-I-I-I-nnnnnnnnnn….” “I’m sorry, what did you say?” I asked, as we laid her back on the stretcher. Her eyes were now fully opened, and I could see her nystagmus. I wondered how fast her world was spinning. “Dee, dee, dee, are, are, eye, eye, eye, en, en, en, kay, eye, en, gee…” she said, sounding to me like she was saying each letter’s name in a slurred, rapid-fire staccato. Lisa, on her way out of the room, stopped short and looked at me as she came back to the bedside. “Where do you go to school?” Lisa asked the girl. “P-r-o-v-i-d-e-e-n-c-e—C-o-o-l-l-l-e-g-e...” she answered in the same machine gun flow of named letters. “Do you know what happened tonight?” I asked “P-a-r-t-y. I-n-t-t-o-x-x-i-c-a-t-e-d-d.” She answered. By now Lisa looked fairly concerned and I wracked my brain, deciding what to do next. In 16 years of practicing emergency medicine and taking care of hundreds of acutely and chronically intoxicated patients, I had never seen one who spelled every answer. Her examination was otherwise normal, but she continued to reply to every question by spelling the answer. Although it would be exceptionally unlikely, I knew that some brain injuries cause “broken language,” or perhaps she had some rare form of autism where this was her method of communication, or perhaps this was a partial seizure causing a bizarre behavior. “What are you going to do?” Lisa, asked. “I’m going to check her electrolytes, CT her head, and watch her until the alcohol goes away.” Several hours later, with a negative head CT and normal electrolyte report in my hand, I walked into the young woman’s room. She was still sleeping but woke up easily. “Where am I?” she asked. “You are in the hospital” I said. “What’s the last thing you remember?” “A few friends and I had a few drinks before we went to the contest. I guess I had a few too many.” “What contest?” “A spelling bee. I wasn’t competing today, just going to cheer on friends.” “So you do competitive spelling?” I asked. “Oh yeah. My whole family does it. You could say it’s in my blood.” She said. “Yes, you could,” I replied.
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Oct 1, 2016
Amer Afaneh + 4
Open Access