A Doctor Without Borders

I smiled as I picked up the last sandwich on the rack. Curried tofu. Surprisingly tasty. People dismissed it too readily. Of course, I also had my doubts before I was forced to choose between it and another 8 hours of hunger. Now it was my go-to. It was slim pickings in the hospital cafeteria in the hour before its midnight closure, but I always knew I would have a meal waiting. That and... I scooted around a stand and grabbed a bag of chips. I may be a doctor, but I threw out being healthy when I was on call. Plus, I hadn’t eaten since breakfast.

I approached the cashier when the most cheerful and yet dreadful sound stopped me cold. The vibration on my hip dashed any hopes that it was someone else's pager going off.

A stroke page.

I was getting too old for this. This was the fourth page in the last two hours, the tenth since the afternoon. Strokes were falling out of the sky. My black cloud had always been terrible, but this streak of bad luck was something else. I needed to get home.

I exhaled to vent my frustration. I shouldn't even be here. A chief resident should be home before six, not midnight. I should have already eaten dinner and been answering pages in the comfort of my underused bed, but Brett. Brett, Brett, Brett. I pitied the first and second years who would work under him shortly. We were at the end of the year, and he was still a train wreck. Because of him, I missed my opportunity to escape before the floodgates opened on admits and strokes.

My pager went off again, and I cursed as I fumbled it and my sandwich. I took a deep breath. Calm.

I checked my pager: ED Bay 3. No pre-notification? Was the stroke missed or did it just happen to a patient in the emergency department? I sighed. The window could be short. I was here. I should lay eyes on the patient. A quick glance at the line was all it took to realize I would have to leave my trusted meal behind.

Please be here when I come back.

When I got home, I wanted to think about sleeping, not eating. I had an hour before this place closed. I should be done in time. Plus, no one likes tofu.

I reached out to put it back on the rack and missed. I had missed my last dose, and it was showing. I didn’t need my body’s constant reminder of my stupid decision to pick this residency. The stroke pager was enough.

I should have just finished my internal medicine residency, but I decided to tack on another three years because neurology seemed so...interesting? I snorted as I raced out the cafeteria. No point lying to myself. I wanted to fix my hands. I had even helped on a clinical trial. My PI made it sound so interesting…

Just two more weeks.

I put my food back, and this time I didn't miss. I headed downstairs to walk through the winding tunnels of the hospital’s basement. I walked, not ran. I earned that right. It was the second-year’s job to be the first assessment.

I pushed through the double doors of the back entrance of the emergency department before hanging a left. I side-stepped a gowned person rushing towards another room at the far end. I tossed a look back. People were spilling out of two separate rooms. Not good. The entire ED seemed to be coding. I snorted. At least I wasn't the only one. Misery loves company.

I found my other resident, Amanda, heading out of the room.

"You ready?”

“Yeah.” I followed her back out of the room thanking God for her. Smart, diligent, quick, and enjoyably sassy. Everything Brett was not.

“What’s the story?"

"Weird.”

I raised my eyebrow. “I noticed no pre-notification.”

“Yeah, because it missed the screen. The ED resident only called after laying eyes on the guy.”

“Not a stroke?”

“Probably…”

“I hear a but.”

“Yeah…”

She was good, but she was still a PGY-2. “Tell me the story.”

She smiled in relief. “It isn’t long. Convenience store clerk called EMS after the patient started acting ‘weird.’ EMS had a good report, and I confirmed it with the clerk" I cocked an eyebrow. "He left his number. Don't let anyone tell you that the people in the city don't care." She was a local through and through. “The guy started to slur his words and then stopped speaking altogether. He passed out on the counter. However, he woke back up with the slightest touch before shortly drifting off again.

“Any convulsions?” She shook her head. I scrunched my face. “I agree. Weird.”

“Yeah.”

“How old is he?”

“Don’t know. No identification. But he looks middle aged.”

"A John Doe?" That was rare. Many of the pages started off that way, but they typically found something or someone.

"Apparently. Didn’t even have a wallet. Not sure how he planned to buy anything if he had no money.”

Mystery for another time. "So, is he even in the window?”

She checked her watch. “Yeah. We have 30 minutes.”

“What is his exam like?”

“Confusing. His stroke scale is high, but it is hard to score because he is so unresponsive. He doesn't appear focal, but I get what the clerk was seeing. He does actually wake up briefly with enough stimulation before falling back asleep.”

"He wakes up?" Atypical for a stroke, but not unheard of...

“Yep, it takes a bit of effort now, but per one of the ED residents, he was quite with it before he would drift off again.”

“So, getting worse.”

“Looks like it. Drug screen and labs are stone-cold normal.”

"Head CT normal?"

"Yeah. No bleed. Not even a hint of a hypodensity to suggest a stroke.

"He was acting normal beforehand?"

"I mean it seems like it. The clerk mentioned the man seemed strangely taken with all the different food options in the store. He was quite vocal with his enthusiasm, but he was acting normally when he started to check out."

"So let me guess. You don't know what it is, but you don't want to give tPA."

She nodded in confirmation. "But I am glad you're here. I would love to have a second set of eyes."

"Alright, let’s see him."

We walked into his room. “Amanda,” I paused a few feet from the stretcher. "What is he wearing?"

His sheets and blankets were flipped over to one side uncovering what looked like a vivid purple gown. Except it could be… I walked closer. It was, and it even had intricate patterns trailing down one side.

“Is that…”

“A robe? Did I not mention that?” She couldn’t hide the playfulness in her voice.

I shook my head. Focus. We were on the clock. "Okay, we have to add catatonia to this differential?"

"Probably not a bad idea, but otherwise he is quite well-groomed and put together. Maybe he was going to or coming from some convention."

It was hard to disagree. He did not appear at all disheveled. “He does wear it well.”

“I know. He is like a model, right? ”

Again, I couldn’t disagree, but I pushed it all to the back of my mind. None of that mattered for his exam.

I stood next to the bed and spoke loudly. “Sir, can you hear me.” Nothing. I tried louder and received the same response.

“I had to use clavicle stimulation to get a response.”

I nodded at Amanda’s comment. I put my hand on his collar bone. “Sir, this is going to hurt.”

I squeezed, and his body jerked up. Both arms flew into the air. His legs kicked. The speed of his movement surprised me. I stepped back almost missing what he said.

"What? What is going on? I can’t feel it. I can’t…”. He collapsed back down onto the stretcher.

“Feel what?” He only mumbled an unintelligible response to my question before drifting off. I put my hand back on his clavicle but didn’t squeeze. I looked at Amanda. “Did he do that for you?”

Her eyes were still wide. “Not like that.”

I stepped back to take him in. I grabbed an arm and lifted it. I let it go, and it dropped like a rock. The same happened for each limb.

“He isn’t really weak.” He had just raised his arms and kicked. Those weren’t posturing positions. When he was awake, he was strong in all extremities.

“I guess not.” She processed it some. “Right. Not with the way he just moved.” She paused a second. “So not a stroke.”

I didn’t comment. I put my palm on his forehead to anchor my hands. Then I placed my fingers on his eyelids. “I am going to open your eyes.” I pulled back his lids and my fingers almost slipped. “Woah.”

One was the darkest black, the other the lightest of blues. I had seen pictures of heterochromia, but nothing like this. Interesting and also totally extraneous.

I waited to see if he would respond. When he didn’t move, I quickly whipped his head back and forth. His eyes moved almost as expected.

“Amanda, I think he has a third.”

“No.” She rushed to the head of the bed. She hated being wrong.

“It is subtle. Watch the black eye. It doesn’t adduct.” I did the maneuver again.

“I am not sure I agree. It does move in a little. I still think he is non-focal.”

I stared at those mismatched eyes. They were not roving. "Not particularly consistent with non-convulsive status. Has he gotten the Ativan?"

"No, I was going to, but I didn't want to confound the exam when I heard you were still in-house.”

I nodded in appreciation before stopping. “How did you know I would come down?”

“Please.”

She had me. This rotation would have been so much better if I had two of her if only because my need to micromanage would be far less with having two residents I trusted.

I let go of his eyes and rubbed his sternum. He grunted and moaned, but he returned to unconsciousness as soon as I stopped.

“What’s the plan?”

A thought had been tickling the back of my brain, and I finally voiced it. "What do you think about a stroke from the artery of Percheron."

She stared at me for a long time. ”Really? You really do like the zebras, don't you?"

I let that comment slide because she was right. Deducing all the different causes was a challenge I enjoyed. Why I thought I should be a surgeon I will never understand. Not that it mattered with my hands. "With the third, it would fit.”

“I can push him to the MRI.” Her voice trailed off.

“We won’t have time.”

“It’s your call,” and it really would be with our current attending. “I can try some lorazepam.”

“That is a fair compromise. Tell the ED to get the tPA ready but have them do 2 mg of lorazepam before starting. If no improvement, push it.” I was hedging my bets, but the lorazepam shouldn't be too sedating…

“I'm going to call Dr. Danziger for his blessing. I will let you know if he changes the plan.”

She snorted as I turned to leave the room. Dr. Danziger would basically do whatever I wanted. Every resident knew he was checked out. We were at the end of the year. In two weeks, I would be making decisions without any oversight. He just gave me free reign a bit early. Probably why he always demanded this time of the year to be an attending.

I found a quiet corner and called him.