Really?

40 year old guy is brought into my tiny rural ER by ambulance.  1 hour ago he suddenly stopped talking, walking or responding to his family.  He also started vomiting.  When I look at him lying on the exam table, I see a left sided facial droop, legs extended, eyes unfocused, and lots of transient decerebrate posturing.  (my first "Really?" moment: I've only seen this in textbooks before...)  No, the family says, he didn't fall and hit his head.   I search for a head wound but don't find one.  I look at his pupils.  They're reactive but unequal.  He doesn't respond to questions or commands.  His response to noxious stimuli is more decerebrate posturing.

For the lay folk out there, decerebrate posturing is extension of the elbows and internal rotation of the shoulders, along with leg extension.  Can also go with neck extension and internal leg rotation, although this guy wasn't showing those signs.  It's a sign of brainstem damage.  No good.  He gets a Glasgow Coma score of 4.  All of us healthy awake people get a perfect score of 15.  4 is a pretty bad score.

Differential diagnosis: brainstem herniation (due to... what?  hemorrage from an unwitnessed drunken fall?  tumor? brain swelling from some other cause?), posterior stroke?

Previous state of health: heavy drinker on the weekends, last drink was last night.  No other known medical problems.   Has seemed very weak for the last 6 months, non-focal as far as I can get out of the family.

I still have no CT scanner here.  Strangely enough, I also have no neurosurgeon.  Also, it's Saturday, so I can't even get basic electrolytes.  His blood glucose is 399.  I place an NG tube, give some diazepam in case he's been drinking a lot less lately and there's a withdrawal component here (although I really don't think that explains the picture I'm seeing).

I spend about 1 hour convincing his family that he needs to be at a bigger hospital.  Preferably one with a CT scanner.  During this time his blood pressure, which was initially about 180/100 bounces up to 240/120, so I start in with the labetalol.  I wind up giving quite a bit of labetalol while trying to simultaneously control his blood pressure and convince the family he doesn't belong in this hospital.  It may be that the diazepam was counter productive.  I think it calmed him a little, and he was less agitated and therefore doing less of the disturbing decerebrate posturing.  The family therefore thought he was getting better, and wanted to take him home, or at least spend the night in my hospital.  ("Really?" moment #2)  I firmly stood my ground, and eventually convinced them he needed to be in a bigger hospital.

So we sent him 4 hours by ambulance with one of my nurses along for the ride.  Unfortunately, the nurse's cell phone has no minutes on it, and we have no cell phones to give her, so she has no way to contact me for instructions en route if problems develop.  ("Really?" moment #3)  So I equip her with a lot of labetalol and a little more diazepam and extremely detailed "if-then" style instructions.

She can receive calls, so we call her periodically to check in.  We learn that the patient is about the same, and has vomited some more.  Also, her blood pressure cuff broke en route, destroying her ability to give labetalol according to my instructions.  ("Really?" moment #4)

On our next call to her we then learn that the big hospital ER in the capital city is refusing to accept this patient.  ("Really?" moment #5).  I try to call and reach a doctor to talk to, but am unable to find my way through the Guatemalan phone system extension maze.

(Note, it's standard practice in the states to call an admitting doctor at the hospital where you're sending the patient before you send them.  Makes sense, right?  But I had been told that here, if you do that, they'll just tell you not to send them, so it's better for the patient to show up on their doorstep with a detailed note from me.  Therefore I had not called ahead.)

We then called our nurse back again and learned that he had been accepted into the hospital after all.
Thank goodness.

You know, in the states we have a law that says any patient who shows up at an ER has the right to be seen.  They have no such law here.  When I'm working in the states and it's another somewhat drunk homeless guy who wants in out of the rain and wants a sandwich (and is extremely picky about exactly which kind of sandwich he wants, and why am I out of tuna currently?), this law annoys me.  At the moment, it seems incredibly important.