There was a crowd of security guards, physicians, and nurses in an ED room. The patient inside squirmed and writhed on the stretcher while sweating profusely, soaking his clothing and the hospital bed. Though slender and slightly cachectic, the patient had fought off the security entourage multiple times, like a snake slipping from their grasp, violently twisting and turning his body. As he struggled, a nurse tore off the sleeve of the patient’s dark blue jumpsuit in order to get IV access and administer medications. The 26-year-old man kept his eyes wide open and stared at the ceiling, which made it easy for me to see his tremendously large and dilated pupils, empty and frightening at once. Seven security guards held him down when the nurse started the IV.
All this went on for about an hour, and as the time passed the monitor above the patient’s bed, which projected his temperature, blood pressure,
and heart rate, changed. The temperature rose: 99…100…101…102…. The heart rate went up to 120 (a heart rate above 100 is considered fast and is called tachycardia). The blood pressure, too, rose
to 160/100 (normal is approximately 120/80). And the patient continued to sweat and writhe. As he exerted himself, his cells produced molecules necessary
for energy, a process which generates heat and increases heart rate and blood pressure.
The patient was experiencing a PCP, or Phencyclidine, overdose. PCP is a drug that was developed in the early twentieth century as an anesthetic. However, the drug also caused
delusions, anxiety, and agitation and was eventually discontinued because of these side effects. In the 1960s, many drug addicts used it illegally in pill
and smoke form. Because PCP acts partially among dopamine receptors in the brain it can cause both
euphoric and, sometimes, psychotic and violent behavior. On medical licensing exams we are expected to recognize the typical PCP symptoms: violent behavior, dilated pupils, profuse sweating and
tachycardia. Additionally, the drug can cause seizures, hyperthermia (very high body temperatures), severe hypertension or high blood pressure – which can
damage the eyes, kidney, and brain as well as other organs – and rhabdomyolysis,
the breakdown of muscle, which can cause further kidney damage. Unfortunately, no medication exists to reverse the drug once it’s been ingested and
treament primarily targets only a patient’s symptoms.
The resident started treating this particular patient with a type of benzodiazepine, a sedative drug
that acts on receptors in the brain to inhibit anxiety and agitation. This class of medications is frequently used for patients who have prolonged
seizures, severe anxiety, or difficulty sleeping. After multiple doses of benzodiazepines over the course of the hour, as well as IV fluids to counteract
possible rhabdomyolysis, the patient continued to fight and his temperature continued to rise. It was almost as if he had not been given any medication at
At this point, the only option was to use drugs to knock the patient out completely, or paralyze him, so that he would stop struggling and his vital signs would
normalize. To ensure the paralytic drugs do not prevent the patient from breathing, a tube is placed down his throat, keeping the airway
open. The resident injected the paralytic into the IV, and once it took effect he
used a glidescope to pry open the patient’s throat in order to visualize
the airway. Then, he stuck a short plastic tube down into the trachea. The hollow tube allows oxygen to pass into the trachea thus acting as the patient’s
mouth and throat. The tube is then connected to a ventilator that pumps air into the lungs and thus keeps the patient oxygenated. A great video
of this procedure with narration is available here.
This last ditch effort worked. Over the next few hours, the patient’s temperature and blood pressure dropped and he avoided the dangerous sequelae of his
toxic ingestion. Although curious to see what would happen to him next, my rotation ended before the patient was admitted to the hospital and I went home
to sleep off the overnight shift.
Thursday, July 10, 2014
A neurology resident’s blog about the inner workings of the field of medicine and its theoretical, practical, and ethical complexities. [More]
Science, Medicine, and Healthcare
- MedCity News
- The Apothecary (Forbes)
- The New Republic on Obamacare
- The Atlantic, Top Stories in Health
- Unofficial Prognosis (Scientific American) [archived]
- This May Hurt a Bit (PLOS)
- Science Daily
- Nature news
- MIT Technology Review on Biomedicine
- Health Blog (Wall Street Journal)
- Well blog (New York Times)
1984 ABC abscess ADHD Affordable Care Act agonal breathing agonist airway albumin albuterol alcohol aldosterone Algis Valiunas ALS Alzheimer’s disease American Scholar amphetamines amygdala Andrew Cuomo Andrew Solomon antagonist anti-vaccination movement anxiety arteries arteriovenous fistula Arthur Conan Doyle asthma attending physician autonomy Avicenna Avik Roy battle benzodiazepene beta-1 receptor beta-2 receptor bias birth blood blood pressure blush Bordetella Pertussis Boston Review botox British Medical Journal burnout cancer capillaries carbidopa-levodopa carbon dioxide cardiac output cardiovascular system Case Files CDC cerebrospinal fluid chemotherapy chlorpromazine Christopher Tollefsen Civil War CNN code combatants Commentary Magazine compressions computers confounding bias contact precaution controlled COPD CPR CT scan cupping cynical cynicism Danielle Ofri death Death with dignity deep brain stimulation defibrillation dehydration delirium delivery delusions dementia depression detachment diabetes dialysis diastole differential diagnosis dilation diuresis Doctor and Doll dopamine dopamine agonists doppler double-blinded Dr. Watson DSM Duke University Dylan Thomas dyskinesia ECMO edema Edward Rothstein EEG EKG electroconvulsive therapy electrolytes Emblems of Mind emergency department emergency medical technician emergency physician emergency room empathy EMTALA epinephrine euthanasia evidence-based medicine expletives face facial expression family febrile seizures fetal station field hospital fighting death Forbes free will Fyodor Dostoyevsky Galen Gaza Geneva Convention George Orwell glia glidescope glucose Google HACE hallucinations Hamas Hamlet health heart heart rate hemoglobin Henri Dunant hepatitis c heroin high blood pressure hiking hippocampus Hippocratic Oath HIV Holocaust Hopital X hospice hospital gown hospitals How the Poor Die How We Die human humor hyperkalemia hyperosmolar hyperglycemic state hypertension hyperthermia hypoglycemia hypophonia hypotension ICU imaging inoculation inpatient insulin resistance intensive care unit introduction intubation iPhone Israel J. M. Peebles jaded JAMA James Parkinson Jean-Jacques Rousseau Jenny McCarthy Jim Carrey John Adams John Donne John Locke jokes Joseph Bell Julia Joffe Kaplan Kay Hymowitz kidney stones kidney transplant kidneys Kilimanjaro labor labs language of medicine lead-time bias Lenox Leo Tolstoy Leon Kass leukemia Lou Gehrig's Disease Louisa May Alcott lower motor neuron lungs mathematics medical school medical student medicine Medscape Memories and Adventures memory mental illness micrographia monoamine oxidase inhibitors morphine MRI multigravid music Musicophilia naloxone narcan neonate neurology New England New England Journal of Medicine New Jersey New York City newborn night shift NMDA No Joke nonadherence nonadherent Norman Rockwell nurse NYU olanzapine Oliver Sacks operating room opioid organ transplant orthopedic surgeon osmotic pressure otolaryngologist outpatient overdose pain Palestinian palliative care paralytic paramedics Parkinson's disease pathology patient plan patient presentation patient satisfaction Paul Bloom Paul McHugh PCP pediatrician pediatrics Peter Singer pharmacist phencyclidine physical exam physician physician-assisted suicide placenta platelets pneumonia Polio politics postpartum potassium practicing medicine pregnancy pregnant prenatal testing pressure ulcer PreTest preventive medicine prostate cancer pseudoseizure psychiatry Public Discourse pulmonary artery randomized red blood cells reflex renin residency resident rhabdomyolysis riluzole risperidone Robert Louis Stevenson Robert P. George Robert Youngson Robitussin romanticization Ronald Reagan Rounds Ruth Wisse Samuel Shem Saturday Evening Post schizophrenia seizure Sherlock Holmes Sherwin Nuland shoulder dystocia shuckling Smallpox smell smirk smoking social worker sodium specialty specimen spinal cord spleen splenomegaly SSRI status epilepticus STEP 2 CK Stephen Bergman Stephen Hawking stroke Sudden Infant Death Syndrome surgery systole tachycardia Tanzania TechCrunch The Brothers Karamazov The Death of Ivan Ilyich The House of God The New Atlantis The New Republic The New York Times The Public Interest The Sign of the Four third year Thomas Szaz Toward a More Natural Science tracheotomy trauma trauma surgeon trial tumor umbilical cord uniform UNRWA upper motor neuron uterine contraction uterus UWorld vaccine criticism Vaccines vascular surgeon veins ventricles ventricular assist device Vinod Khosla vital signs Wall Street Journal war war crime warfarin Whooping Cough William Osler
- ► 2015 (13)
This blog will contain frequent references to patients and their illnesses. In order to protect patient and hospital privacy and obey the law, I will not mention any significant identifiers for patients or hospital staff. I will ensure their privacy by altering age and gender when necessary, and by describing events only when sufficient time has passed, so that it is impossible for readers to know when a patient appeared at the hospital. I will, however, remain loyal to the facts relevant to these vignettes when they do not come in conflict with the privacy of the people involved.
By way of a warning, some of these posts contain graphic descriptions of medical conditions and procedures. These descriptions may be troubling to some readers, but they contribute an essential component to the full picture of how medicine works.