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Emergency Medicine News:
doi: 10.1097/01.EEM.0000443917.53853.bb
Diagnosis Deconstructed

Diagnosis Deconstructed: Our Duties Defeated

Morchi, Ravi MD

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Dr. Morchi is the director of the Medical Screening Examination program at Harbor UCLA Medical Center and an assistant professor of emergency medicine at UCLA's David Geffen School of Medicine.

I look to my left and then to my right. I cannot decide which is worse.

Figure. Room 2: Sile...
Figure. Room 2: Sile...
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Figure. Room 1: Hydr...
Figure. Room 1: Hydr...
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One room is bursting with high-intensity activity. The patient has a bug-eyed stare, his eyes darting from side to side. He is oddly hyperalert and at the same time completely lost. He can speak but the words are garbled. The sentences are nonsensical if they can be made out at all. I have seen others like him frothing at the mouth and banging their heads against the wall or the railing off the cot. Trying to get that NG tube out, I imagine. Maybe the face mask off? They don't like anything near their mouths. But in their strange desperation, they fail to realize that their hands are not tied. Simultaneously frantic and seemingly hypervigilant, they actually lack all awareness of their bodies and the immediate environment.

The second room has no activity. We try to keep it quiet and dark. Don't want to disturb him. He lies perfectly still, but not of his own volition. Any sudden noise or light will be more than just a perception; it will startle. A setback in his clinical condition comes with startling. What took days to knead out of his muscles with Valium will resume in an instant with a loud noise or abrupt movement around him.

Assuming the frozen arched position of a perfectly balanced porcelain figurine with only his occiput and heels touching the cot. Quite a sight: an unbendable, unmovable young man.

The suffering in room 2 is deeper than the motor unit. Emotionless? No, he is in there. Expressionless? Actually, no. He carries a fixed smile or frown. Not for a particular moment or reason but for every moment and no reason, regardless of how he feels inside. The illness is an overdose of motor function, to be sure. But equally so, it is a cruel preservation of mental function. Fully cognizant and entirely aware of what he is not able to do. He is horribly frightened inside, and unable to express it. Given the choice, would he trade places with his brethren in room 1?

His old soft tissue wound is cleaned, and he is given metronidazole early on, but he will lie like this for days or weeks more, suffering for long periods before he either dies in a fit of muscular hyperactivity and metabolic acidosis or a storm of laryngeal muscle spasm that ends air entry. If he is one of the fortunate few, after an undetermined period of darkness, intense benzodiazepine therapy, and passive immunity injections, he will loosen up enough to sit and then later stand and walk.

What would he give to have motion? To unlock his body? To be like his neighbor? He knows that man well. Not by sight but sound.

The neighbor on the other hand knows nothing of the silent statue lying meters away. He continues romping around his room, banging his head and salivating. Screeching and sometimes howling with eyes bulging. A frenetic performance that will terminate in convulsions and collapse within 48 hours. Disarrayed cortical neurons spare him from fully appreciating his own pain in the interim, however.

If our duty as physicians is to save lives, then room 1 has beaten us. It is nearly uniformly fatal. Encephalopathy can be salvation from suffering, but a terminal illness waits. And the final act is approaching quickly.

If on the other hand it is our duty to relieve suffering, then room 2 proves a more formidable foe. It is the thorn that sits in our flank that we cannot remove. We often cannot end the physical or mental pain in the resource-limited environments where it actually occurs.

Mama Doris is a nurse from another era. She wears a tall white hat and gown reminiscent of the early 1900s British system upon which our hospital is modeled. I sometimes imagine she has been practicing since then. She pulls me aside to inform me of something.

Not much for subtleties, she essentially says this: The patient in room 1 needs to leave. He does not have to go home, but he cannot stay here. He is causing trouble. He is making too much noise, and with every yelp comes a spasm from room 2 and another round of pain and agony. Room 1, after all, is terminal. His family is willing to take him home and hold him down until he dies. I suppose we can provide them some oral sedatives, should the poor fellow be agreeable to swallowing the pills.

I am not aware of any reported cases of human-human transmission, and I have to admit he is still technically an infectious mammal, not unlike the one that bit him weeks ago. I wonder who in these parts would have actually bothered to report it if there were ever transmission by man. Mama Doris? Doubtful.

So I complete his discharge paperwork and proceed to inform his family: handle him with care until his day comes. It will not be long. His life is not salvageable, and our duties fall to alleviating suffering now. Fortunately, we can rely on his deepening encephalopathy to mute some amount of pain.

And just like that it is quiet again. Room 2 is left with his barren, endless days of staring at the ceiling punctuated by brief nursing visits and his medication. We doctors stop by for a few minutes each day but remain strangers to him.

He will wait, hopeless and helpless with sensory function unaltered. He can do little to intervene if a bug lands on his face. He cannot relieve it if his toe itches. His family and their bedside vigilance mean everything to him now. He has an intimate sense of just how delicate life is and just how important our relationships are. And he has nothing to do but think about these things. Weeks go by, and I see he still lies there. I increase his dose of Valium to the point that consciousness and airway protection are sacrificed to maximize respiratory muscle function. A peculiarity of treating this condition in the resource-limited, non-ICU, sometimes we have to put B before A.

I wonder if he wishes for death. A relief from agony. An option to go the way of his old roommate weeks ago. To exit in a final dance of ignorant freedom, rabid motion, and unregulated vocals. A quick end to his current personal hell of hyperactive motor units directing myosin to pathologically anchor into actin while higher cortical neurons remain seamlessly synapsing and processing every sensation and every thought indefinitely.

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* Read all of Dr. Morchi's past columns at http://bit.ly/MorchiCollection.

* Comments about this article? Write to EMN at emn@lww.com.

© 2014 by Lippincott Williams & Wilkins

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