Sunday, December 31, 2023
1300 hrs
The nurse calls about your next patient, a 20-year-old woman who is behaving erratically. From their behaviour– the patient came in with a friend–she feels that she is withdrawing from a drug and will need to go to hospital.
You arrive and the patient’s friend immediately confronts you with talk.
She catches you off guard, actually. You are taken aback but not perturbed, just uncomfortable at first. You find her (the patient) writhing in bed and her friend sitting at the bedside, immediately trying to engage you with history and with conversation. The nurse has moved on to another patient in another room and so it is just you, the patient, and her friend. The friend conveys the concern in rapid-fire sequence that the patient may need psychiatric help and is under a lot of stress. You speak briefly with the friend as the patient is resting and initially non-committal. She seems in pain, writhing in bed and unable to get comfortable. You learn that this lady was on psychotropic medication but is not on any now–the details of which medication and when are not known. The friend’s chatter is insistent and consistent, that her friend may need psychiatric help. You address the patient, and she responds and says she has abdominal pain, but her responses are erratic and staccato and not infrequently she responds with: “I don’t know.” You ask about associated symptoms to her abdominal pain and she volunteers that she has had diarrhoea, associated nausea, but has not vomited. The answers are so erratic that you decide to move quickly to a systems review, asking briefly after headache, fever, and chest pain. You do a quick assessment of her: her pupils are 3 mm reactive; she’s speaking briskly; HS dual nil added. Chest is clear. Abdomen soft. She is oriented to person and place but not to time. But in amongst these responses, is what increasingly becomes her main response: “I don’t know,” she retorts. You sense that she is being defensive. But you don’t know; because she says it reflexively and in an indifferent manner.
You decide to hold off on your examination for a moment, while you ponder the situation. As the history is not forthcoming, or at best sketchy, and she stable–albeit restless and erratic*–you change tack, almost without thinking (to try an alternate approach).
“Do you want a cup of tea?,” you say.
“Yes,” she nods, sitting up and clutching her belly. You are surprised by her reply.
“How do you have it? White?”
“Yes.”
“One sugar?”
“Yes.”
Being polite, you turn to her friend and ask her also.
“Tea?”
“Yes, thank you,” she blurts out. “Milk and one sugar,” she says abruptly.
The nurse returns looking busy as always. You ask her nevertheless to take some obs and, as you both slowly walk away from the bedside and take each other’s thoughts in confidence, you tell her that you might try the “talking cure” on this one.
You go to the staff room and make two cups of tea: white, one sugar. You return with the teas and they gladly accept the offer. Your order some labs, incl. lipase and beta-HCG, even a venous blood gas (that’s you at your super-clinic best, you think–no one telling you what to do, your ass orders a venous gas.).
They take a sip or two and you turn to find a theatre stool just beside you, and you sit down.
Your demeanour is at a mismatch to the patient’s presentation. You learn that this lady has used drugs in the past. It is over a year ago now since she last used ICE, and then only for a month. She denies having used today. She injected it but denies any other IVDU. She smokes cigarettes, doesn’t drink, and does not smoke cannabis. She is on no regular medications. She has no allergies. She remains, however, restless and erratic and complaining of abdominal pain and of feeling hot, with the occasional moaning and groaning, and the occasional “Oh my God!” as she writhes in bed; sits up; sits down; lies down; and sits up again. Then she lies down and seems to dose off … or zone out. You question her friend who is fixated on the idea that her friend needs to see a psychiatrist. You ask whether she may have used anything today. She denies it.
Anxious now, you determine to check your patient over once more, starting with her pupils: This time they’re a 4 and sluggish, though equal. She’s clammy, and your initial thought when you first arrived and were accosted by her friend that she may be having a panic attack comes abruptly to an end. You worry. Is she about to fit? Is she displaying cerebral irritation? Is she septic and if so from where? Too many thoughts flood your head. You pace up and down a few times and regather your thoughts.
You read the nurses obs off the piece of paper towelling they’ve been written on. They sit next to the side of the bed on a parcel shelf, just below the cardiac monitor, sitting silent as if waiting to come to life:
BP (sitting): 133/84
Pulse: 125
Temperature: 36.2
Resp. rate: 20
O2 saturation: 98%. (*always confirm the oxygen saturation in any patient who is restless or erratic)
And just then another of her friends arrives and you learn from him that earlier in the day, at about quarter past 10, she smoked some ICE. Nil other drugs use, apparently.
You put in an IV and start 1L Normal Saline at a brisk rate, drawing bloods before starting the fluids. Remembering to always check a BSL in someone acting erratically: you do a bedside BSL and it is 6. You recheck her pupils; this time using a different light source, and they’re 3-4 mm and reactive. You think you might send this woman to the ED after-all. “Have you called (for) an ambulance,?” you ask the nurse.
You chart for 2.5 mg risperidone PO and go to your room.
You see some of the general practice patients while you wait for the fluid to run into her and decide whether to refer or to keep her. Perhaps 5 minutes later, you hear a bit of a kerfuffle coming from the acute side. After 5 minutes, you wander down to learn that she has pulled her cannula out and walked out. …
This was a case where the nurse was right from the get-go. (Lesson 4: With nurses, you’ve got to know when to hold ’em, know when to fold ’em, and know when to run.)
Sympathomimetic toxidrome:
This is similar in presentation to an anti-cholinergic syndrome, except for skin and bowel differences.
Blind as a bat, mad as a hatter, red as a beet, hot as hare, dry as a bone; the bowel and the bladder lose their tone, and the heart runs alone.
- diaphoresis
- mydriasis
- tachycardia
- hypertension
- hyperthermia
- seizures
- increased peristalsis
Depending on the timing of their presentation, however, you may variably see the patient in the midst of a toxidrome or in withdrawal from the drug which, generally, will present with opposite symptoms.
