Wednesday, September 14, 2011

The Lion's Roar

“Roooaaarrrrrrrrr!”

“What was that?” I said to the nurse sitting next to me.
“It sounded like it came from the patient behind you,” said the nurse.
I spin around in my chair. My eyes make contact with an elderly man lying in bed. His hair is white and reminds me of Albert Einstein, the way it sticks up from his head. He is covered in a white blanket. I walk over to find out more.
I check his chart. “Mr. Altman, what brings you to the hospital today?” I ask.
He responds after a 5-second delay. “My head. It is pounding. Right here,” Mr. Altman said as he pointed to a small spot on the right side of his forehead about 3 inches above his eyebrow. “I've never had pain like this before; never a migraine, not even a headache. I don't know what is wrong but I just don't feel well,” he says.
“What was that roar I heard before?” I asked.
“What roar?” he replies.
I decide not to pursue the issue.
I look at the man standing next to Mr. Altman. “Hi, I am Steve, Mr. Altman's son.”
“Hi, Steve. Can you tell me more about your father's headache?”
“Well, I noticed my father was not acting like himself this evening. He seemed confused. He forgot my name and didn't know the date. This is unusual. He never complains either. You know, he survived the Holocaust.”
I performed a quick physical exam on Mr. Altman, focusing on the neurological aspects. I asked him to smile, raise his eyebrows, puff out his cheeks, and stick out his tongue—looking for the slightest imperfection to signal a neurologic dysfunction. He performed all of these functions perfectly. Then I tested his motor skills. I asked him to push, pull, and raise various parts of his body against resistance. Again, all was normal. I cannot isolate a neurologic abnormality and therefore decide to order a head CT scan and alert the stroke team of a possible stroke.
I wheeled Mr. Altman across the hall to the CT scanner. The radiology technician positioned the stretcher next to the CT table. We slid Mr. Altman onto the table and strapped him in. We placed folded sheets on each side of his head so it does not move—careful to avoid streak artifact and degrade the quality of the scan. We double check to make sure everything is in place and leave the room.
The tech entered the orders into the computer and told Mr. Altman to hold still. “Don't move even an inch,” the tech says over the loudspeaker. The large mouth of the CT scanner swallows Mr. Altman. We all watch as the images appear slice by slice.
“Oh boy,” I say to myself. “That does not look good!”
Mr. Altman's brain was being compressed by an epidural hematoma. The blood is located exactly where Mr. Altman pointed to when we spoke just minutes ago. If this condition is not corrected, Mr. Altman's brain will start to herniate through the foramen magnum, leading to rapid decompensation and likely death. We don't have much time.
The tech walks over to open the door. I see him struggling with it so I ask what is happening. He says he cannot open the door. It is jammed. “What do you mean?” I ask. I push past him, and wiggled the handle and thrust my shoulder against the door. It doesn't budge. It's clear the door is not jammed, but locked.
“Who has the key?” I ask the tech.
“What key?” he replies, dead serious. “I never lock this door. I have never even seen a key ever used in this door.”
I peered into the room through the glass window and saw Mr. Altman lying on his back on the CT scanner table. He doesn't know we can't get him out.
“Call security,” I said. “Maybe they have a key.”
Security arrives minutes later with a ring of keys.
“Are you going to save the day?” I ask the guard. “Please tell me that one of those keys will open this door!” Five minutes and at least 20 keys later, I asked the clerk to call the fire department. “We need this door open now.”
While we waited for the fire department, we kept checking on Mr. Altman. We told him over the speaker not to worry, we are going to get him out soon. He doesn't respond. We can barely see his face because he is lying on his back inside the CT scanner. I started thinking about his brain filling with blood, pressure quickly building, causing his breathing to gradually slow and eventually stop. This man survived the Holocaust, I say to myself; he can hold out a few more minutes. I tried to see his chest rising but he is covered with so many sheets. I kept watching and waiting.
I decided not to wait any longer.
A security guard and I rammed our bodies into the door. It didn't budge. We took a few steps back to get some momentum, and then both of us hit the door at the same time. Nothing. I peer into the room and see Mr. Altman's face. His eyes are closed and I still can't tell if he is breathing. I look at the security guard and tell him we have to get this door opened. We raised our legs and kicked the door as hard as possible. I heard a crack. We kicked it again and again. Finally the door swung open. I rushed over to Mr. Altman's side. As I pulled down the blanket that partially covered his face all I hear is “Rooooaaaarrrrr,” coming from the mouth of Mr. Altman. Again, I am not sure what this is. I check his vital signs, which are unchanged.
We returned to the emergency department and called the neurosurgeons so that they could operate on Mr. Altman's hematoma. I explained the diagnosis to Mr. Altman's son and briefly discussed the next steps. I shook the son's hand and wished him luck. Just as I am about to walk away to see my next patient, I stopped and turned around. “Have you ever heard your father roar before?” I ask.
“Oh, his yawn,” the son said. “He's been doing that his whole life. He kind of sounds like a lion, doesn't he?”
I nod. He sure does.
[Ann Emerg Med. 2009;54:625-626.]

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