In the emergency department, I frequently have need to aggressively get control of patients in order to get tests that might save their lives. At the same time, aggressive control carries risks so I often face tough choices of how to best control a patient for his benefit. At work one night, I had to go to CAT scan (CT) twice. It is just down the hall from the emergency department but I almost never have to go down there. It was very unusual to have to go twice in one shift. I had to go there to help control two challenging patients who both had potentially life threatening conditions.
The first guy I had to go see was in his twenties. He came in telling me he was nervous and had palpitations after taking cocaine and methamphetamines. His heart was beating fast and he was jittery but was thinking normally.
In such cases, we usually just give them something to help them relax. We watch them for a while until they are better and send them home. This guy, on the other hand, just got worse and worse. Even after being given the sedatives I ordered, he began hallucinating and his agitation increased. Over a relatively short time we gave him a ton of medicine and he finally fell asleep. Minutes later, he woke up fighting, agitated and pulled out his IV. Then he fell back asleep.
One rare complication of stimulant drug abuse is a brain hemorrhage caused by the elevated blood pressure and excess agitation. I felt I needed to scan his head to rule out a hemorrhage but he needed to sit still for a few minutes in order to perform the scan. As soon as we tried to move him to the scanner, he would wake up and thrash around again. We gave him so much medicine I was afraid he would stop breathing but whenever he was moved he became too agitated to sit still in the scanner.
Finally, at the recommendation of one of the nurses, we got a spine board and strapped him down like he was a trauma patient. We wrapped straps around his body and tape on his head and neck. We then took him to CT. Once he was given some more medicine and was left on the CT table for a few minutes, he relaxed and we were able to get a scan that showed his brain was OK.
All of this was a huge pain but, in the end, all of his tests were normal except for the cocaine and methamphetamines in his urine. Over the next several hours, he didn’t wake up so he had to be admitted to the hospital for further observation and care.
The second guy provided almost exactly the same challenge but in a very different situation. Right at the end of my shift, a young man came in after having had a seizure. He was two weeks out from having an arteriovenous malformation* (abnormal blood vessel) removed from his pons** (lower part of the brain). He had been doing well after his surgery until that night when he had a seizure. He was still unconscious when the ambulance got him to us.
We did our initial assessments and treatments in record time and the nurses headed off with him to CT. They soon called saying he was thrashing around. I had sent them with instructions to give him a sedative if he seized again or wouldn’t sit still. They had followed my instructions but he hadn’t responded to the medicine. I gave orders for more medicine. That didn’t work either. They were unable to scan him, as he wouldn’t lie still.
I hurried down to CT with another nurse and more medicine. I was finally able sedate him adequately to get him to sit still just long enough for the scan. It showed he had bled into his brain at the surgical site.
It was very challenging to get him to sit still. But it was a big bummer to see the hemorrhage. It had caused the seizure and the agitation, and was also probably going to lead to his death.
So, in the first case, the patient brought his problems upon himself by taking too many stimulant drugs. His CT was normal and he would probably be fine. The second guy had the really bad luck of bleeding after brain surgery. His CT was positive and he was certainly going to have a bad result. It shows why it is so important to be able to get control of such patients to get their studies so any needed care can be provided in a timely fashion.
I love it – now you are teaching us. Great blog. Thanks, Tad!