Code Blue

“Code blue medical clinic; code blue medical clinic; code blue medical clinic.”

I stopped typing and listened. I was the only one. Overhead announcements come and go in the emergency department. If your name isn’t mentioned, you don’t pay attention. Unless, of course, you’re bored out of your skull from hours of mundane research work.

I stared at the ceiling tiles where the overhead speakers were, as if the emergency were visible there. I could picture the scene: a mad scramble in the clinic, about 50 feet down the hallway.

“Code blue medical clinic; code blue medical clinic; code blue medical clinic”, the page operator repeated. Two more repeats would be coming.

Lindsay, a research assistant working at the computers with me, followed my eyes.

“Where’s the medical clinic?” she asked, neck craned upward.

I looked down the hallway to my left. “I’ll show you” I said, and stood up. Lindsay hopped out of her chair and fell in step beside me as we headed for the hallway.

“Cool.” She said. “How come you guys don’t usually go to these things? I mean, you’re like the emergency experts, right?” Lindsay asked.

I shrugged, “ED’s too busy most of the time to be running around the hospital. They’ve got a code team for that.”

Lindsay’s eyes narrowed, “Okay. So why are we going?”

I answered. “We’re close, I guess.”

Lindsay nodded, skeptical. 

“Code blue medical clinic; code blue medical clinic; code blue medical clinic”.

A security guard raced past us in the hallway, radio crackling. Lindsay was ahead of me now. Bold. A striking blonde surfer, Lindsay was dead set on medical school and had spent the last few months doing research in the ER. I did not doubt her future.

As we neared the clinic we could see through the glass walls into the waiting room. A sofa blocked our view of everything below the knees. No code team yet, just two guards in the center of the room looking down, toward the floor. Every few seconds one would hop slightly as if avoiding a mouse.

We entered the room and I walked toward Rob, a muscle-bound, usually jovial security guard. He answered before I asked.

“You tell me, doc.” Rob pointed to a black man in his late thirties to early forties, fully clothed with leather jacket and scarf, writhing around on the floor. The clinic was silent except for the shuffling of leather on tile. In the chairs around us bewildered patients stared. 

I studied the man as he moved. He lay in a fetal position on his side and all parts of him seemed to be in motion. Repeatedly, he unfurled an arm and fist and hand, and then straightened each leg, separately. He struck a brief pose at maximum extension, then withdrew again into the fetal position. With each breath his face puckered into a kissing position, followed by a horse-like, lip-smacking exhale. His trunk and limb movements were snakish and smooth. His eyes were far away. 

I crouched next to him. The man’s life did not appear to be in grave danger. His color was normal and his skin was warm and moist. Touching his wrist revealed a pulse that was slightly elevated and a blood pressure that was not dangerously low. He did not respond to questions or touches. There was no odor of incontinence and no rhythmic muscle contraction. His pupils were reactive and normal.

Lindsay looked at me, eyes wide, and asked “Drugs?”

I kept watching. The man was still safe, medically. His air movement was good, his oxygen levels seemed fine, and his blood pressure and pulse were relatively normal.

I relaxed my brain and waited to see if pattern recognition would come. Nothing. I had not seen this. I looked around for data.

In a class I was teaching at Columbia, a class Lindsay was taking, we explored how physicians and scientists think. Personal experience and pattern recognition are valuable but what a doctor has seen does not determine what they will see. Medicine is too broad and the variables too many, to rely on the past. Contrary to popular belief, nobody has seen it all.

I focused on the secretary who was standing behind her intake desk.

“Ma’am,” I asked, “does anyone here know this gentleman?”

She pried her eyes from the man on the floor and looked at me with an expression that fell somewhere between disgust and fear, but said nothing.

I tried again, “Did anyone come with him, did he have an appointment here?” She did not respond. “Ma’am, is there a medical record for this gentleman in the office?” 

She looked back down at the man, still writhing, and said nothing.

A physician behind the desk was looking at a large sign-in book and recognized me. She stepped forward. The man had come alone, she said. He’d been in the waiting room a few minutes, then approached the desk. Before he could speak, he began flailing his arms and fell to the floor. The staff called the code blue. There were three appointments in the current time slot for men in the sign-in book, and none had yet been seen by a doctor. The first was for a man with a tumor of the pancreas, another was for a man with high blood pressure, and a third was for a gentleman with schizophrenia and heart disease. It was Monty Hall: door one, two, or three?

“Were they all here for routine appointments, or did any of them have a specific complaint?” I asked.

The clinic physician looked at her book “All routine.” 

Lindsay looked at me, biting her lip. “Is it um, a stroke?”

Three more security guards appeared, panting, and behind them the code team. The senior resident was a familiar face. I told him the story while we watched the man continue his strange modern dance. The resident asked me what I thought. Lindsay leaned in.

In my head I re-capped. This apparently functional and seemingly healthy young man was sitting in the clinic waiting room when he began suddenly to display involuntary movements. He was unresponsive to verbal communication, and to physical stimulation. His vital signs were normal except a mildly elevated heart rate. He had likely been diagnosed with high blood pressure, an abdominal tumor, or schizophrenia.

The story was typical of a seizure, which can result from countless underlying problems—metabolic derangements, drugs, bleeding or cancer in the brain, epilepsy, and others. People with high blood pressure are at higher risk for stroke, which can cause seizures. But stroke-related seizures are rare. And was it even a seizure? The movements were definitely not typical, he hadn’t lost control of his bodily functions, and his pupils were normal. I filed through the types of seizures I had seen and could think of none that looked like this. I put stroke or seizure low on the list.

The nature of his movements was striking, and I thought about what I knew of neurologic movement disorders. They’re focused in the brain and the spinal cord, they can be secondary to infection or metabolic problems, and they’re the most common cause of athetosis—snake-like movements this gentleman seemed to be exhibiting. But they shouldn’t render him unconscious, or less responsive. I ruled out a movement disorder, at least as a full explanation.

My instinct was that this was systemic. It was affecting his brain, but the brain wasn’t necessarily the origin. His whole body seemed involved: The respiratory system (his breathing pattern), the central nervous system (his movements, and consciousness), the skin (sweating), and the cardiovascular system (heart rate) were all abnormal. Systemic problems are often metabolic, like electrolyte imbalances, infections, toxins, or overdoses. I thought about drug reactions, and blood pressure medicines which occasionally cause electrolyte imbalances (door two, high blood pressure). I considered psychiatric medicines, which are famous for movement disorders (door three, the schizophrenic). I considered chemotherapy, medicines that make a body susceptible to infection (door one, cancer). I considered street drugs (any door, any time).

Finally, I considered the ‘once-everything-else-is-ruled-out’ diagnosis: Psychiatric disease. Psychiatric disease was prone to take almost any form, and it was possible this was behavioral. No innate, organic bodily illness I had ever seen looked like this, making psychiatric illness a possibility.

I answered the resident, “Drug reaction seems likely, but it could be psych.” Lindsay nodded and watched while the resident considered.

The ancient Greeks were the first to apply scientific method to medicine, but their name for medicine belied this: they called it ‘The Art.’ Experience and judgment are critical for diagnosing and treating illness, and yet the human mind is often misled by anecdote. Faulty inductive thinking is the cause of many, maybe most, mistakes in medicine. More than 2,400 years ago Hippocrates wrote “Life is short, the Art is long, opportunity fleeting, experience delusive, judgment difficult”. Some things don’t change. 

Suddenly, the man seemed to find control. His movements slowed and he hoisted himself into a standing position. He stood looking at no one in particular, his chin tucked in towards his chest, his arms at his sides, his gaze fixed on nothing. At over 6 feet he was an imposing figure. There was a scramble, people in the waiting room began backing up and heading for the door. All five security guards surrounded him. I stood out of reach.

Rob stood in front of him and asked “How you doing, sir?”

No answer. Again he asked, “How you doing, sir?”

The man’s right arm unfurled, as did his left leg, like a robot out of control. His fist missed Rob’s chin by inches and his foot struck Rob lightly on the shin. Rob and the four guards all pounced, taking the man back to the floor. He was strong and it was a melée.

While the six of them struggled I asked the clinic physician what medicines they had on hand. She showed me a drawer with emergency meds – epinephrine, dextrose, lidocaine, diphenhydramine, atropine, haloperidol. I took a syringe, filled it with 5 milligrams of haloperidol and injected the man’s leg while the guards wrestled with him on the floor.

The man began to make noises. He yelled “No!” as I injected him. His speech was nearly incomprehensible at first but soon became articulate yelling.

“You think you can take me? I’m all that! I’ll take you all!” He moved his head furiously. “Treat me like a man! Takes ten of you, you think you tough? You ain’t tough!”

A stretcher was brought in and the man was lifted onto it. We rolled down the hall while he ranted. As we pushed him into the ED his eyes began to sharpen. I asked “What’s going on, sir? Are you alright?”

He panted a few times, then spit at me. I dodged his saliva and asked again, more sternly. “What’s your name?”

He panted again and jerked his head toward me, screaming between gritted teeth. “FUCK you!”

His eyes gradually became distant and wild again. He tilted his head back on the stretcher and began to growl. His ankles were now tied to the railings on the bed and the guards were trying to tie his wrists, two guards each holding his arms and one laying across his chest. The man did a sit-up, taking the guard on his chest with him. Now all five guards, two nurses, Lindsay, and I, all helped to hold him down while others tied his wrists.

I pressed my forearm hard into his forehead and the bridge of his nose, causing pain and covering his face whenever he tried to lift his head. When he rested his head back I pulled away. Physical incentives often work, even in psychotic and drugged patients. Still, he lifted his head numerous times and numerous times I pushed down hard into his nose and forehead. After a few minutes his gaze grew more focused and he slowed his fighting.

“Sir, do you know where you are?” I asked. I was breathing heavily, waiting for the medicine I’d given to kick in.

He replied, “You think you tough, huh? I’ll kick all your asses, every one of you. Wanna try me one on one? Let’s go.”

“I cannot help you unless you stop fighting, sir. Do you understand?” I virtually pleaded with him, my forearm and whole body tiring. “As long as you are fighting, I have to keep my staff safe. If you stop fighting and talk to me I can help you.”

He raised his head slightly and lifted his right arm, snapping the cloth restraint holding it down. He grabbed a guard by the shoulder with his newly freed hand and screamed “Fucking pussies!” as he tried to punch the guard with his other hand. The arm restraint held.

I slammed his head down to the mattress and pressed hard until his arms and legs were re-tied, this time in leather restraints. When I lifted my arm his forehead was red and his nose was bleeding.

I shook my head in disgust, and let his head go. I stepped back to breathe, and re-assess. I was now sure it was drugs or psychosis, maybe methamphetamines, or cocaine, or PCP, a stimulant of some sort. I was panting and angry and ordered a second sedating agent. With leather restraints in place, the nurses started an IV line and drew bloods. A young nurse walked into the room with a syringe full of sedating medicine, followed immediately by a weathered ER nurse named Mike, just back from a smoking break. Mike looked at the man on the stretcher, then the security guards, then me. He smirked. He turned to the man on the stretcher.

“Daniel, what’s up?” said Mike. “Your sugar low again?”

The man grunted.

Mike turned to me, “He’s got an insulinoma, sugar drops. How low is it today?”

I looked at Mike, sighed deeply, and shook my head slowly. Lindsay looked from Mike to me.

Mike raised his eyebrows and bore into me with a stare. “Worth checking,” he said.

I didn’t need to check. The man’s sugar would be low, and I knew it. I didn’t know it before, but I did now. A rare cancer of the pancreas, an insulinoma, sporadically pumps insulin into the bloodstream causing sugar levels to drop quickly, sometimes leading to erratic or violent behavior, seizures, or unconsciousness. Door number one: Tumor of the pancreas.

Low blood sugar is one of the most common reasons for altered consciousness, and I’d missed it. Checking the sugar should be done instantly on anyone confused or unconscious, and it takes seconds. I taught my residents this lesson every day, and hawked over them to be sure they always complied.

Daniel’s sugar was 48, half normal. I gave him dextrose through his IV. Three minutes later he was calm and conversant. Permanent brain damage can happen with longer periods of low sugar, so it needs to be identified and corrected quickly. Daniel didn’t seem to have any damage—except a developing bruise on his forehead and blood oozing from his nose.  

I turned to explain to Lindsay, to teach her anything, to regain control, to salvage. But she was back at the computers. Mike too had walked out.

I was alone with Daniel, a gentle, kind, and thankful soul. I brought him orange juice, and a snack, and sat with him. We talked, I told him how sorry I was. He waved it away.

“Doc, y’all been good to me” he said, dabbing at his nose.

Every now and then I plan to post a short like this. Feedback is ALWAYS welcome—want more of these or this type of content? Less? Suggestions? Bring it on, I can take it….